MEBICAL 

Lira. 

SCHOOL 
AKY 

John  liar  shall  Willicoison 
Memorial 


OUTLINES  OF  ANATOMY 


STUDENTS 


A    GUIDE    TO    DISSECTION 


BASED    ON    MORRIS'S    TEXT-BOOK    OF   ANATOMY. 


BY 

WILLIAM   A.  CAMPBELL.  M.  D., 

DEM"N>TRATOR   OF  ANATOMY   IX   THE   MEDICAL   DEPARTMENT  OF  THE   UNIVERSITY  OF  MICHIGAN. 


PHILADELPHIA: 
P.    BLAKISTON,   SON    &    CO., 

1012    WALNUT    STREET. 
1495. 


COPYRIGHT,  1895,  BY  P.  BLAKISTON,  SON  &  Co. 


PRESS  OF  WM.  F.  FELL  &  Co., 

1220-24  SANSOM  ST., 

PHILADELPHIA. 


tf 


CONTENTS. 


THE  HEAD  AND  ANTERIOR  CERVICAL  STRUCTURES.  PAGK 

Superficial  Anatomy  of  the  Head  and  Face, 9 

Dissection  of  the  Scalp, 9 

Structure  of  the  Cranium, 1 1 

The  Cranial  Cavity, 1 1 

The  External  Orbital  Region, 14 

Dissection  of  the  Orbital  Region  and  Face, 15 

The  External  Ear, 19 

THE  NECK. 

Superficial  Structures, 19 

Posterior  Triangle, 21 

Anterior  Triangular  Space, 21 

General  Description — 

Inferior  Carotid  or  Tracheal  Triangle, 22 

Superior  Carotid  Triangle, 22 

The  Submaxillary  or  Supra-hyoid  Triangle, 23 

Middle  Line  of  the  Neck, 24 

Dissection, 26 

Temporal  and  Pterygo-maxillary  Regions, 31 

Submaxillary  or  Supra-hyoid  Region, 34 

Deep  Dissection  of  the  Neck, 35 

Prevertebral  Region.     Articulations, 36 

Dissection  of  the  Pharynx 37 

The  Soft  Palate, 38 

The  Tongue, 39 

Larynx 39 

Dissection  of  the  Larynx, 40 

Internal  Orbital  Region, 41 

Otic  Ganglion.     Maxillary  Division  of  the  Fifth  Nerve,  etc., 43 

The  Nasal  Fossae.     Meckel's  Ganglion,  etc. 43 

Middle  Ear.     Internal  Ear, 45 

Dissection  of  the  Eyeball, 47 

Dissection  of  the  Brain, 49 

Landmarks  of  the  Back, 57 

Dissection  of  the  Posterior  Cervical  Structures  and  the  Back, 58 

The  Spinal  Cord,  Spinal  Nerves,  etc., 6l 

THE  UPPER  EXTREMITY. 

Landmarks  of  the  Thoracic  R;gion,  Shoulder,  and  Axilla, 62 

Dissection  of  the  External  Thoracic  Region  and  Axilla, 63 

The  Shoulder, 66 

Landmarks  of  the  Arm,  Elbow,  and  Forearm, 67 

Dissection  of  the  Arm  and  Forearm, 67 

Forearm, 69 

Landmarks  of  the  Wrist  and  Hand, 70 

iii 


iv  CONTENTS. 

PAGE 

Dissection  of  the  Wrist  and  Hand, 70 

Articulations, ....  73 

Articulations  of  the  Upper  Extremity, 73 

THE  THORAX  AND  THORACIC  VISCERA 76 

The  Articulations  at  the  Front  of  the  Thoiax, 86 

The  Articulations  of  the  Ribs  with  the  Vertebrae, 86 

•The  Articulations  of  the  Vertebral  Column, 87 

The  Male  Perinseum, , 87 

Female  External  Genitals  and  Perinseum,      89 

THE  ABDOMINAL  WALLS. 

Superficial  Anatomy  of  the  Abdomen, 90 

Dissection  of  the  Abdominal  Walls.     Inguinal  Hernia.     Umbilical  Hernia, 91 

The  Abdominal  Parietes,      91 

Parts  Concerned  in  Inguinal  Hernia 93 

Parts  Concerned  in  Umbilical  Hernia, 93 

The  Scrotum, 93 

Spermatic  Cord, 94 

The  Abdomen  and  Its  Contents 94 

The  Pelvic  Viscera, 102 

The  Thigh, 109 

The  Knee, 109 

Dissection  of  the  Front  of  the  Thigh, 109 

Femoral  Hernia, no 

The  Inner  Side  of  the  Thigh, 112 

Gluteal  Region, 112 

Popliteal  Space, 114 

Back  of  the  Thigh, 115 

The  Leg, 115 

The  Ankle, 115 

The  Foot, 115 

Dissection  of  Front  of  Leg  and  Dorsal  Surface  of  Foot, 116 

Peroneal  Region, 117 

Posterior  Tibio-fibular  Region 117 

Sole  of  the  Foot, 118 

The  Articulations, 120 

The  Various  Kinds  of  Articulations, 120 

The  Various  Movements  of  Joints, 120 

The  Articulation  of  the  Pelvis  with  the  Spine, 121 

Articulations  of  the  Pelvis, 121 

The  Articulations  of  the  Lower  Limb, 121 

The  Hip-Joint, 121 

The  Knee-joint, 121 

The  Tibio-fibular  Union, 122 

The  Ankle-Joint, 122 

The  Tarsal  Joints, 122 

Tarso-metatarsal  Articulations, •  .    .    .        123 

Intermetatarsal  Articulations, 123 

Arches  of  the  Foot 1 24 

The  Metatarso-phalangeal  Articulations 124 

Interphalangeal  Joints, 1 24 


To  THE  STUDENT. 

In  this  outline  the  numbers  refer  to  the  pages  and  plates  in  Morris's  Anatomy, 
dated  1895.  (The  numbers  in  parentheses  refer  to  the  edition  of  Morris  dated 
1893.  This  edition  is  identical  with  that  dated  1895,  with  the  exception  of  the 
paging.)  Looking  on  the  page  referred  to,  it  will  be  seen  that  the  corresponding 
heading  is  printed  in  heavy-faced  type,  and  the  paragraph,  or  portion  of  paragraph 
following  it,  should  be  read.  The  structures  of  each  region  should  be  studied  suc- 
cessively, in  the  order  indicated  by  the  outline.  The  student  should  carefully  work 
out  each  structure,  studying  each  part  fully  as  it  is  exposed,  comparing  with  the 
description  in  Morris.  All  structures  should  be  carefully  exposed  in  place  in  order 
that  the  relations  may  be  properly  studied  and  no  part  should  be  cut  or  removed 
except  as  indicated.  When  a  heading  is  inclosed  in  a  parenthesis  it  is  to  indicate 
that  the  structure  mentioned  cannot  be  fully  exposed  at  that  point  in  the  work,  but 
will  be  shown  at  another  period  of  the  dissection. 


OUTLINES   OF  ANATOMY. 


THE  HEAD,  AND  ANTERIOR  CERVICAL  STRUCTURES. 

Superficial  Anatomy  of  the  Head  and  Face. 

Bony  landmarks,  1111-12-13.     (1088-9-90) 

Lambda.     Bregma.     Pterion. 
The  bony  sinuses,  1113-14-15.     (1091-2) 
The  frontal. 
Mastoid  sinuses. 
Sphenoidal  sinuses. 
Arteries,  1117-18.     (1094-5-6) 

Supraorbital.     Temporal.     Occipital.     Posterior  auricular. 
External  carotid.     Facial.     Frontal  artery. 
Parotid  duct.     Sheath  of  the  parotid,  1119.     (1096) 
Position  of  the  lachrymal  puncta,  lachrymal  sac,  1120-1 ;  Fig.  66"].     (1097) 

Manipulation  of  a  probe  along  the  lachrymal  passages. 
The  Mouth,  1121-2-4;  Fig.  668.     (1098-9-1101) 

Wharton's  ducts.     Fraenum.     Sublingual  glands. 
Submaxillary  gland.     Genio-hyo-glossi.     Lingual  nerve. 
Coronoid  process.     Hamular  process  of  the  sphenoid. 
Tonsils : — 

Relations  of  the  tonsils. 

Finger  introduced  downward  at  the  back  of  the  mouth. 
If  the  finger  be  moved  upward.     Size  of  the  nares. 
The  palate : — 

Isthmus  faucium. 
The  Nose,  926.     (905—6) 
Nose  proper : — 

Root.     Bridge  or  dorsum.     Top  or  lobe.     Base. 
Nostrils.     Columna.     Vestibule. 
Alae  or  wings. 
Bony  framework. 
Cartilaginous  portion. 
The  Scalp,  1115.     (1092) 
Layers :     Fig.  663. 

(i)  Skin.     (2)  Subcutaneous  fat  and  fibrous  tissue. 

(3)  Occipito-frontalis  and   aponeurosis.     (4)  Subaponeurotic   layer.     (5) 
Pericranium  and  subpericranial  connective  tissue. 

Dissection  of  the  Scalp. 

Skin,  hairs,  sebaceous  glands,  1115;  Fig.  663.     (1092) 

Carefully  remove  the  skin  and  expose  (2)  the  layer  of  subcutaneous  fat  and  fibrous  tissue,  in  which 
will  be  found  the  superficial  nerves  and  vessels.  To  remove  the  skin,  make  a  median  incision  from  the 
root  of  the  nose  to  the  external  occipital  protuberance,  and  a  transverse  incision  from  the  lower  end  of 
the  mastoid  process  on  one  side,  over  the  vertex  to  the  corresponding  point  on  the  opposite  side.  Con- 
nect the  ends  of  these  incisions  by  horizontal  incisions  on  each  side,  as  follows  :  Beginning  in  front  at 
the  root  of  the  nose,  make  an  incision  along  the  superior  border  of  the  orbit  to  the  outer  angle  of  the 

2  9 


io  OUTLINES  OF  ANATOMY. 

eye  and  backward  to  the  tragus  of  the  ear,  then  over  the  ear  to  the  transverse  incision.  Also,  an  in- 
cision from  the  lower  end  of  the  mastoid  process  backward  to  the  occipital  protuberance,  connecting 
the  ends  of  the  transverse  and  median  incisions.  Begin  at  the  vertex  and  turn  the  skin  down  and  off. 
Much  care  must  be  exercised  to  turn  off  the  skin  only,  as  the  three  outer  layers  of  the  scalp  are  closely 
connected  together.  The  nerves  and  vessels  should  then  be  carefully  exposed. 

The  superficial  fascia,  452.     (447) 
Subcutaneous  fat,  (2)  1115.     (1092) 
Superficial  nerves,  Fig.  449;  P.  809.     (791) 
Branches  of  the  frontal,  796.     (778) 
Supraorbital  nerve. 
Supratrochlear  nerve. 

Temporal  branch — of  the  orbital  or  temporo-malar  nerve,  798.     (780-1) 
Temporal  branch — of  the  facial  nerve,  810.     (791) 
Auriculo-temporal  nerve,  803.     (785) 
Anterior  auricular  branches. 
Superficial  temporal  branches. 
Posterior  auricular  nerve,  808.     (790) 
Great  auricular  nerve,  830.     (810-11) 

Mastoid  branch.     Auricular  branches. 
Lesser  occipital  nerve,  829-30.     (810) 

Auricular  branch.     Mastoid  branch.     Occipital  branches. 
Great  occipital  nerve,  827.     (808) 
Vessels  of  the  scalp,  ir  16.     (1093) 
Arteries :  — 

Frontal  branch,  533;  Fig.  334.     (524) 
Supraorbital  artery,  531.     (522) 

Temporal  artery  or  superficial  temporal  artery,  521-2.     (513) 
Branches  of  the  temporal  artery  : — 

Middle  temporal  branch  or  middle  deep  temporal  artery. 
Orbital  or  zygomatico-orbital  branch. 
Anterior  terminal  branch,  secondary  branches. 
Posterior  terminal  branch. 

Posterior  auricular  artery,  520-1  ;  Fig.  335.     (512) 
Anterior  terminal  or  auricular  branch. 
Posterior  terminal,  or  mastoid  or  occipital  branch. 
Occipital  artery — third  part  of  its  course,  519  ;  Fig.  335.     (511) 
Terminal  or  superficial  branches,  520.     (512) 
Veins  of  the  head  and  neck,  648.     (635-6) 
Superficial  and  deep. 
Superficial. 
Deep  veins. 

Superficial  veins  of  the  scalp  and  face,  648;  Fig.  385.     (636) 
Anterior.     Posterior.     Lateral. 
Anterior  vein,  648-9-50.     (636) 
Frontal  vein. 
Tributaries. 

Supraorbital  vein. 
Lateral  veins,  652.     (639-40) 
Anterior  lateral  veins  :  — 

Superficial  temporal. 
Middle  temporal  vein. 

Orbital  branch. 

Posterior  lateral  veins,  653.     (640-1) 
Posterior  auricular  vein. 

Tributaries. 
Posterior  vein,  651-2.     (639) 

Occipital  vein. 

Emissary  veins,  ii  16.     (1093) 
Lymphatics,  688.     (673) 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  n 

Lymphatics  of  the  head  and  neck  : — 
Superficial.     Deep. 

Superficial  lymphatic  vessels  of  the  scalp,  689  ;  Fig.  398.     (674) 
Superficial  lymphatic  glands  of  the  head  and  neck,  689  ;  Fig.  398.     (674) 
Transverse :  — 

Occipital  or  suboccipital  glands. 
Posterior  auricular  or  sterno-mastoid  glands. 
Muscles  of  the  head,  Fig.  309  ;  P.  453.     (448) 
Occipito-frontalis,  454-5.     (449-50) 

Occipitalis  and  frontalis  and  epicranial  aponeurosis. 
Occipitalis  : — Origin.     Insertion. 
Frontalis  : — Origin.     Insertion. 
Epicranial  aponeurosis. 

Structure.     Nerve  supply,  Occipitalis,  frontalis. 
Action.     Relations.     Variations. 

Make  a  median  incision  three  or  four  inches  in  length  through  the  aponeurosis  of  the  occipito-frontalis, 
also  a  short  lateral  incision.  Raise  a  small  portion  of  the  aponeurosis  and  expose  the  subaponeurotic 
layer. 

Subaponeurotic  layer,  1115.     (1092-3) 

Pericranium  and  subpericranial  connective  tissue.     1115.     (1092) 

Extrinsic  Muscles  of  the  Auricle,  458-9;  Fig.  309.     (452-3) 

To  demonstrate  these  muscles,  draw  the  auricle  in  a  direction  from  the  point  of  origin,  when  the  fibers 

will  be  rendered  prominent  and  can  be  exposed. 

Attollens  aurem  :  — 

Origin.  Insertion.  Structure.  Xerve-supply.  Action.  Relations. 
Attrahens  aurem : — 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
Retrahens  aurem  : — 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
With  a  chisel  chip  off  a  small  portion  of  the  outer  table  of  the  skull  cap  and  examine  the  diploe. 

Structure  of  the  Cranium,  1116-17.     (I093-4) 
Two  layers  and  intervening  cancellous  tissue. 
Outer.     Inner. 
Diploe. 

Veins  of  the  diploe,  655-6  ;  Fig.  386.     (642-3) 
Frontal.     Fronto-sphenoidal 
Fronto-parietal  or  anterior  temporal. 
External  parietal  or  posterior  temporal. 

Occipital  or  parieto-occipital. 

Results  of  the  above  varying  elasticity,  1016-17.     (1093-4) 

Anatomical  conditions  tending  to  minimize  the  effects  of  violence  inflicted  upon  the 
skull,  1117.  (1094) 

(1)  Density  and  mobility  of  the  scalp. 

(2)  Dome-like  shape  of  the  skull. 

(3)  Number  of  bones. 

(4)  Sutures. 

(5)  Internal  membrane. 

(6)  Elasticity  of  outer  table. 

(7)  Overlapping  of  some  bones. 

(8)  Presence  of  ribs  or  groins. 

(9)  Buttresses. 

(10)  Mobility  of  the  head  upon  the  spine. 
Remove  the  skull-cap  in  the  manner  indicated,  Dissection,  710.     (694) 

The  Cranial  Cavity. 
The  menmges,  710.     (694) 

Dura  mater,  arachnoid,  and  pia  mater. 
Dura  mater,  711.     (695) 

Outer  or  periosteal  lamina. 


12  OUTLINES  OF  ANATOMY. 

Dura  mater:  — 

Inner  or  supporting  lamina. 
Pacchionian  glands,  716.     (700) 
Deep  veins  of  the  head  and  neck,  655.     (642) 
A  cranial  sinus,  711.     (695) 

Venous  sinuses  of  the  cranium,  656-7.     (643) 

Open  the  superior  longitudinal  sinus  by  a  median  incision ;  trace  it  from  the  foramen  caecum  to  the 
internal  occipital  protuberance. 

Superior  longitudinal  sinus,  657-8.     (643-4-5) 
Torcular  Herophili. 

Turn  off  the  lateral  portions  of  the  dura  mater  in  the  manner  indicated,  and  note  the  cerebral  veins, 
Dissection,  711.  (694-5 ) 

Subdural  space,  715.     (699) 
Veins  of  the  brain,  661.     (648) 

Cerebral  veins. 

Cortical,  hemispherical,  or  superficial  veins. 

Superior  cortical  veins. 
Falx  Cerebri,  714.     (698) 

Divide  the  falx  cerebri  in  front  and  throw  it  backward  and  out  of  the  longitudinal  fissure,  and  carefully 
remove  the  brain;  to  do  this,  tilt  the  head  back,  carefully  raise  the  frontal  and  olfactory  lobes  from  the 
anterior  fossa,  divide  the  optic  nerves  and  the  ophthalmic  arteries  just  back  of  the  optic  foramen. 
Divide  the  internal  carotid  arteries  also.  In  the  median  line  behind  the  optic  commissure,  the  pituitary 
body  lies  in  the  sella  turcica,  covered  by  the  dura  mater,  but  connected  with  the  brain  by  the  infundibu- 
lum.  Divide  the  infundibulum  close  to  the  dura  mater.  The  third  pair  of  nerves  will  next  be  exposed, 
and  should  be  carefully  divided  midway  between  the  brain  and  the  dura  mater.  Proceed  thus,  dividing 
each  pair  of  cranial  nerves  as  they  are  displayed.  Divide  the  tentorium  near  its  attached  border  and 
push  it  back ;  the  medulla  and  cerebellum  can  then  be  raised.  Cut  the  spinal  cord  low  down  in  the 
canal  and  divide  the  vertebral  arteries  where  they  emerge  from  the  dura  mater.  The  brain  can  then  be 
removed,  and  should  be  placed  in  spirit  or  Muller's  fluid  and  properly  hardened  before  dissection.  The 
dura  mater  lining  the  base  of  the  cranium  should  then  be  examined.  The  cranial  nerves  should  be 
exposed  and  traced  to  place  of  exit  from  the  cranial  cavity.  Each  of  the  venous  sinuses  should  belaid 
open  with  the  point  of  the  knife  and  their  communications  noted.  Finally,  the  pituitary  should  be 
exposed  and  removed  and  its  structure  studied. 

The  dura  mater,  diaphragma  sellse,  712.     (696) 
Tentorium  Cerebelli,  714-15.     (698-9) 

Upper  surface.     Under  surface.     Free  border.     Attached  border. 
Falx  Cerebelli,  715.     (699) 
Diaphragma  sellae,  715.     (699) 
The  Cranial  Nerves,  786-7-8.     (769-70) 
Superficial  and  deep  origins. 
General  distribution  : — 
Nerves  of  special  sense. 
Motor  nerves. 
Mixed. 

In  the  following  list  the  place  of  exit  of  each  cranial  nerve  is  stated.  The  superficial  and  deep  origins 
will  be  studied  later.  A  statement  of  the  course  of  each  nerve  will  be  found  in  the  general  descrip- 
tion, to  which  the  reference  is  given.  The  distribution  of  each  nerve  will  be  gradually  developed  as 
the  dissection  proceeds. 

(Modified  from  Holden.) 
The  Cranial  Nerves:  — 

First,  or  olfactory  nerve,  788.     (770) 

From  the  under  aspect  of  the  bulb  proceed  about  twenty  branches,  which 
pass  through  foramina  in  the  cribriform  plate  of  the  ethmoid  bone. 
Second,  or  optic  nerve,  790.     (772) 

Passes  through  the  optic  foramen  into  the  orbit,  accompanied  by  ophthalmic 
artery. 
Third,  or  oculo-motor  nerve,  791.     (774) 

Passes  through  the  dura  mater  close  behind  the  anterior  clinoid  process, 
traverses  the  outer  wall  of  the  cavernous  sinus,  and  enters  the  orbit  through 
the  sphenoidal  fissure. 


HEAD   AND   ANTERIOR   CERVICAL   STRUCTURES.  13 

The  Cranial  Nerves  : — 

Fourth,  or  trochlear  nerve,  793.     (775) 

Passes  through  the  dura  mater  a  little  behind  the  posterior  clinoid  process. 
It  passes  through  the  outer  wall  of  the  cavernous  sinus,  lying  below  the 
third  nerve  and  above  the  first  division  of  the  fifth,  and  then  runs  forward 
through  the  sphenoidal  fissure,  passing  above  the  third  nerve. 

Fifth,  or  trigeminal  nerve,  794.     (776) 

The  fifth  nerve  passes  through  an  aperture  in  the  dura  mater  under  the  free 
border  of  the  tentorium  at  the  apex  of  the  petrous  portion  of  the  temporal 
bone.  It  consists  of  two  parts — a  larger  or  sensory  root,  and  a  smaller  or 
motor.  Upon  its  sensory  root  is  developed  a  large  ganglion,  the  Gasserian 
ganglion  ;  the  motor  root  passes  below  and  is  not  connected  with  it.  From 
this  ganglion  proceed  the  three  primary  divisions  of  the  nerve,  the  ophthal- 
mic, maxillary,  and  mandibular. 
Gasserian  ganglion,  795.  (777) 

Ophthalmic  division  of  the  fifth  nerve,  795.     (777) 
Maxillary  division  of  the  fifth  nerve,  797.     (780) 
Mandibular  division,  801.     (783) 

Sixth,  or  abducent  nerve,  805.     (787) 

The  sixth  nerve  pierces  the  dura  mater  behind  the  body  of  the  sphenoid 
bone,  which  it  grooves.  It  then  passes  along  the  inner  wall  of  the  caver- 
nous sinus,  external  to  the  internal  carotid  artery,  and  enters  the  orbit 
through  the  sphenoidal  fissure. 

Seventh,  or  facial  nerve,  806.     (788) 

Passes  outward  through  the  meatus  auditorius  internus. 

Eighth,  or  auditory  nerve,  811.     (792) 

Passes  outward  through  the  internal  auditory  meatus  with  the  facial.  It  is 
the  larger  of  the  two  nerves,  and  lies  below  the  facial. 

Ninth,  or  glosso-pharyngeal  nerve,  813.     (794) 

Tenth,  or  pneumogastric  nerve,  815.     (796) 

Eleventh,  or  spinal  accessory  nerve,  819.     (800) 

The  three  nerves  pass  through  the  jugular  foramen,  the  ninth  in  front  of  the 
pneumogastric,  the  eleventh  behind  it. 

Twelfth,  or  hypoglossal  nerve,  820.     (801) 

Passes  through  the  anterior  condyloid  foramen. 

The  sinuses  should  now  be  demonstrated.     Trace  each,  laying  it  open  with  the  point  of  the  knife. 

Venous  sinuses  of  the  cranium,  656-7-8-9-60-1.     (643-5-6-7-8) 
Inferior  longitudinal  or  inferior  sagittal  sinus. 
Straight  sinus,  or  sinus  rectus.     Torcular  Herophili. 
Occipital  sinus,  marginal  sinuses. 
Lateral  sinus.     Transverse  sinus.     Sinus  jugularis.     Sigmoid  sinus. 

Right  lateral  sinus.     Left. 
Cavernous  sinus  : — 

In  front.     Internally.     Posteriorly. 
Circular  sinus,  or  intercavernous  sinuses. 

Anterior,  posterior,  inferior,  etc. 
Superior  petrosal  sinus. 
Inferior  petrosal  sinus. 
Transverse  or  basilar  sinus. 
Spheno-parietal  sinus,  or  sinus  alae  parvse. 
Petro-squamous  sinus. 

The  cranial  sinuses,  711.     (695) 
Larger  system : — 

Superior  longitudinal,  inferior  longitudinal,  straight,  occipital,  petrosal. 

Torcular  Herophili.     Lateral  sinuses. 
Smaller  system : — 

Spheno-parietal,  cavernous,  circular,  transverse,  inferior  petrosal  sinuses. 
Emissary  veins,  711,  1116.     (695,  1093) 


14  OUTLINES  OF  ANATOMY. 

Intercranial  portion  of  the  internal  carotid,  529.     (520) 
Branches  of  the  intercranial  portion,  530.     (521) 

Arteria  receptaculi. 

Pituitary  branches. 

Gasserian  or  gangl ionic  branches. 

Meningeal  or  anterior  meningeal  branches. 
Middle  or  great  meningeal,  524.     (515-16) 

Anterior  branch. 

Posterior  branch. 

Gasserian  branches. 

Petrosal  branch. 

Tympanic  branch. 

Orbital  or  lachrymal  branch. 

Anastomotic  or  perforating  branches. 
Meningeal  arteries,  713.     (696-7) 

In  the  anterior  cranial  fossa : — 

Anterior  meningeal  branches. 
Twigs — from  middle  meningeal. 

In  the  middle  cranial  fossa : — 

Branch — of  ascending  pharyngeal. 

Meningea  parva. 

Meningeal  branch  of  internal  carotid. 

In  the  posterior  cranial  fossa : — 

Meningeal  branches — from  occipital. 

Twigs — from  occipital  and  ascending  pharyngeal. 

Meningeal  branch — of  the  vertebral. 

Lymphatics  from  the  interior  of  the  cranium,  691.     (676) 

Meningeal. 

Cerebral  lymphatics. 
Carefully  raise  and  throw  forward  the  Gasserian  ganglion  and  expose  the  petrosal  nerves. 

Great  superficial  petrosal  nerve,  800,  808.     (782,  789) 
Lesser  superficial  petrosal  nerve,  808.     (789) 
External  superficial  petrosal,  808.     (789-90) 
Carotid  plexus,  865.     (845) 

Tympanic  branch. 

Great  deep  petrosal  nerve. 

Branches  to  the  Gasserian  ganglion. 

Branches  to  the  sixth  nerve. 
Cavernous  plexus,  865.     (845) 

Communicating  branches  to  the  third,  fourth,  and  ophthalmic  divisions  of  the 

fifth  cranial  nerves. 

Sympathetic  root  of  the  lenticular  ganglion. 

Twigs  to  pituitary  body. 
Pituitary  body,  or  hypophysis  cerebri,  749.     (732) 

Anterior  lobe. 
Posterior  lobe. 
Pituitary  gland,  pituita. 

A  pad  should  be  placed  in  the  base  of  the  skull  and  kept  properly  moistened  with  preservative  solution, 
to  prevent  the  structures  from  drying. 

The  External  Orbital  Region. 

Examine  the  eyeball  and  its  surroundings  before  the  skin  is  removed  from  the  face. 

The  Eyeball  and  its  Surroundings,  874-5-6-7.     (854-5-6-7-8) 
General  surface  view,  Fig.  472. 
Palpebral  aperture. 

Outer  and  inner  canthus. 

Lachrymal  caruncle.     Plica  semilunaris. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  15 

The  Eyeball  and  its  Surroundings  : — 

Upper  eyelid,  tarsus  (superior  palpebral  fold). 

Lower  eyelid  (inferior  palpebral  fold). 

Edges  of  eyelids  (a),  (b).     (Meibomian  follicles.) 
Lachrymal  papilla. 

Palpebral  conjunctiva,  fornix. 

Lachrymal  caruncle.     Semilunar  fold  of  conjunctiva,  878.     (858) 

Ocular  conjunctiva,  876.     (856) 

Scleral  sulcus. 

Zones  of  iris ;  ciliary,  pupillary. 

An  examination  of  the  living  eye  should  be  made  with  the  aid  of  the  ophthalmoscope,  and  the  follow- 
ing mentioned  structures  identified  : — 

Optic  disc  or  papilla.     Lamina  cribrosa. 
Yellow  spot.     Fovea  centralis. 

Dissection  of  the  Orbital  Region  and  Face. 

Moderately  distend  the  cheeks  with  tow  and  stitch  the  margins  of  the  lips  together.  Treat  the  eyelids 
in  the  same  manner.  Continue  the  incision  in  the  median  line  of  the  face  to  the  chin.  Beginning  at 
the  root  of  the  nose,  make  a  semicircular  incision  outward  along  the  lower  border  of  the  orbit  to  the 
outer  angle  of  the  eye.  Also,  make  an  incision  downward  in  front  of  the  ear,  and  forward  along  the 
lower  border  of  the  inferior  maxilla  or  mandible  to  the  median  line.  Beginning  in  front  of  the  ear, 
turn  the  skin  forward  to  the  median  line,  and  remove  it.  Care  must  be  exercised  to  remove  the  skin 
only,  especially  over  the  ala  of  the  nose  and  the  chin,  where  it  is  closely  adherent  to  the  subjacent  struc- 
tures. The  skin  of  the  eyelids  should  then  be  removed,  by  carefully  reflecting  it  to  the  margin  of  the  lids 
from  above  and  below.  The  structures  of  the  external  orbital  region  will  be  first  considered. 

Superficial  fascia,  452.     (447) 

Structure  of  the  lids,  1119-20.     Fig.  666.     (1097)     902.     (881) 

Skin.     Areolar  tissue. 
Muscles  of  the  eyelids  and  eyebrows.     Upper  tarsal  cartilage,  455.     (450) 

Carefully  expose  the  orbicularis  palpebrarum.  Preserve  the  branches  of  the  facial  nerve  which  enter 
its  deep  surface,  on  the  outer  side. 

Orbicularis  muscle,  musculus  ciliaris  Riolini,  902.     (881) 
Orbicularis  palpebrarum,  455-6 ;  Fig.  309.     (450-1) 
Internal  tarsal  ligament  or  tendo-oculi. 
External  tarsal  ligament. 
Orbital  portion  : — 

Origin  and  Insertion. 
Palpebral  portion : — 

Origin.     Insertion. 

Structure.     Nerve-supply.     Action.     Relations. 
Orbicularis,  1120.     (1097) 

The  dissectors  of  the  opposite  sides  will  now  work  together,  and  continue  the  dissection  of  the  external 
orbital  structures  on  the  left  side,  in  the  manner  indicated.  Discontinue  further  dissection  of  the  right 
eye  at  this  point,  and  preserve  it  for  dissection  later,  with  the  internal  orbital  structures. 
On  the  left  side,  beginning  at  the  outer  edge,  raise  the  orbicularis  and  reflect  it  inward.  Care  must  be 
exercised  not  to  injure  the  palpebral  structures  underneath.  The  corrugator  supercilii  and  tensor  tarsi 
will  be  demonstrated  as  the  orbicularis  is  raised. 

Corrugator  supercilii,  457-8;  Fig.  310.     (452) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Tensor  tarsi,  457;  Fig.  310.     (451) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Central  connective  tissue,  903.     (881)     Palpebral  ligament,  1120.     (1097) 
Blood-vessels.     Nerves  :   (a)  Sensory  ;  (b)  Motor,  904.     (883) 
Tarsus,  superior  palpebral  muscle,  903.     (881-2) 

To  expose  the  insertion  of  the  superior  palpebral  muscle,  divide  the  superior  palpebral  ligament  along 
the  border  of  the  orbit  and  reflect  it  downward  to  the  tarsus. 

Palpebral  conjunctiva,  903.      (882) 
Lymphatic  vessels  of  the  lids,  904.     (883) 
Glands  of  the  eyelids,  903.     (822-3) 

Meibomian  glands,  lashes,  and  sebaceous  follicles,  1120.     (1097) 


1 6  OUTLINES  OF  ANATOMY. 

The  Lachrymal  Apparatus,  904-5-6  ;   Fig.  492.     (883-4-5) 

Lachrymal  gland. 

Carefully  expose  the  anterior  portion  of  the  lachrymal  gland  in  place,  raise  it  slightly,  and  tease  out  the 
minute,  thread-like  ducts  passing  from  the  gland  to  the  conjunctival  sac. 

Puncta  lachrymalia. 
Canaliculi  lachrymales. 

Insert  a  small  probe  or  a  blunt  pin  in  the  canaliculi  and  trace  them  to  the  lachrymal  sac,  opening  the 
canal  with  the  point  of  the  knife. 

Lachrymal  sac. 

Inner  palpebral  ligament  or  tendo  oculi,  Horner's  muscle,  904.     (883) 
Outer  palpebral  ligament,  904.     (883) 

Strip  the  ocular  conjunctiva  from  the  surface  of  the  left  eye  and  expose  the  tendons  of  the  orbital 
muscles  at  their  insertion.  Each  tendon  can  be  raised  and  supported  on  a  small  splinter  while  the 
insertion  is  studied.  See  Fig.  481,  P.  890.  (869) 

Muscles  of  the  orbit,  891 ;  Figs.  481,  474.     (870-1) 
Superior  and  inferior  recti. 
External  and  internal  recti. 
Superior  and  inferior  obliques. 
Elevator  of  the  upper  lid. 

The  student  will  now  continue  the  dissection  of  the  face.  The  risorius  and  platysma  will  first  be 
exposed.  The  facial  branches  of  the  great  auricular  nerve  should  be  traced. 

Risorius,  465  ;  Fig.  309.     (459) 

Origin.     Insertion.     Structure.      Nerve-supply.      Action.     Relations. 
Platysma  myoides,  452-3-4;  Fig.  309.     (447-8-9) 

(Origin.)     Insertion.     Structure.     Nerve-supply.      Action.     Relations. 

Divide  the  platysma  along  the  lower  border  of  the  inferior  maxilla  or  mandible,  turn  the  facial  portion 
forward  to  its  terminal  insertion,  then  remove  it. 

Facial  branches — of  the  great  auricular  nerve,  831 ;  Fig.  451.     (8n) 
Parotid  fascia,  468.     (462) 

Carefully  dissect  off  the  fascia,  exposing  the  parotid  gland  in  place,  and  trace  its  duct  forward  to  the 
point  where  it  enters  the  buccinator.  The  branches  of  the  facial  nerve  and  the  transverse  facial  artery 
will  be  seen  emerging  from  the  anterior  border  of  the  gland,  and  in  exposing  the  gland  great  care  must 
be  exercised  not  to  injure  these  structures.  One  of  the  branches  of  the  nerve  should  be  traced  back  to 
the  main  trunk  of  the  facial,  cutting  away  the  substance  of  the  gland  in  order  to  expose  the  nerve  and 
other  structures  passing  through  it.  From  the  main  trunk  the  radiating  branches  should  be  traced  for- 
ward to  their  terminal  distribution,  carefully  clearing  away  the  fat  and  connective-tissue.  During  the 
process  of  exposing  the  branches  of  the  facial  nerve  the  muscles  and  vessels  of  the  face  will  be  gradu- 
ally developed,  and,  so  far  as  possible,  should  be  exposed  in  place  without  injury. 

The  salivary  glands,  982;  Fig.  559.     (961) 
Parotid  gland,  982-3-4.     (961-2-3) 
Superficial  area. 

Pterygoid,  glenoid,  and  carotid  lobes.     Socia  parotidis. 
Duct  of  the  parotid. 

Arteries.     Veins.     Nerves.     Lymphatics. 
The  facial  nerve. 

After  its  emergence  from  the  stylo-mastoid  foramen,  the  facial  nerve  runs  down- 
ward and  forward  within  the  substance  of  the  parotid  gland,  and  terminates  by 
dividing  into  two  divisions — an  upper  or  temporo-facial,  and  a  lower  or  cervico- 
facial.  Six  branches  are  given  off  from  the  terminal  divisions  of  the  facial 
nerve :  — 

(3),  pes  anserinus,  809-10;  Fig.  449.     (790) 

Muscles  of  the  mouth,  461 ;  Fig.  309.     (455) 
Orbicularis  oris,  461.     (456) 

Angular  muscles  of  the  mouth,  464;  Fig.  309.     (458) 
Zygomaticus  major,  464.     (458-9) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Depressor  anguli  oris,  465-6.     (459-60) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.      Relations. 


HEAD   AND   ANTERIOR    CERVICAL    STRUCTURES. 


Muscles  of  the  mouth  : — 

Labial  group  of  Muscles,  466.     (460) 

Levator  labii  superioris  alaque  nasi,  466.     (460) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.      Relations. 
Levator  labii  superioris,  466-7.     (460-1) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.      Relations. 
Zygomaticus  minor,  467.     (461) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
Divide  the  levator  labii  superioris  transversely,  midway  between  the  origin  and  insertion.  Reflect  the 
upper  portion  to  the  origin  and  the  lower  portion  to  the  insertion,  and  expose  the  levator  anguli  oris. 
Care  must  be  exercised  not  to  injure  the  vessels  and  nerves  in  reflecting  the  muscle. 

Levator  anguli  oris,  464-5.     (459) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Depressor  labii  inferioris  or  quadratus  menti,  467.     (461) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Expose  the  buccinator.     In  cleaning  the  muscle  avoid  injury  to  the  nerve  branches  on  its  surface.     The 
alveolar  origin  will  be  shown  ;   the  origin  from  the  pterygo-maxillary  ligament — (2) — will  be  demon- 
strated at  a  later  period  of  the  dissection. 

Buccinator,  462-3-4;  Fig.  311.     (457-8) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
The  orbicularis  oris  should  now  be  fully  exposed  and  its  parts  demonstrated.     To  expose  the  incisive 
slips,  evert  the  lip  and  strip  off  the  mucous  membrane,  when  they  can  be  readily  shown. 

Orbicularis  oris,  461-2;  Fig.  311.  (456) 
Attachments  to  bone: — (i),  (2),  (3). 
Structure : — 

Fibres : — Transverse  set,  labial  portion. 
Vertical  fibres,  facial  portion. 

Sagittal  or  antero-posterior  fibres,  in  labial  portion. 
Musculi  incisivi. 

Nerve-supply.     Action.     Relations. 

Evert  the  lower  lip  and  draw  it  downward  ;  strip  off  the  mucous  membrane  and  expose  the  levator  menti. 
Levator  menti,  468.     (462) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Muscles  of  the  Nose,  459-60-1,  429-30;  Fig.  516.     (453-4-5,  907-8) 
Pyramidalis:  — 

Origin.       Insertion.       Structure.       Nerve-supply.       Action.        Relations. 
Variation. 
Compressor  narium  : — 

Origin.     Insertion.     Structure. 
Depressor  alae  nasi :  — 

Origin.     Insertion.     Structure. 
Dilator  naris  anterior : — 

Origin.     Insertion.     Structure. 
Dilator  naris  posterior : — 

Origin.     Insertion.     Structure. 
Vessels  of  the  nose,  nerves,  930.     (909) 
Arteries. 
Veins. 
Nerves. 
Facial  nerve  : — (Motor). 

Temporo-facial  division,  810.     (790-1) 
Temporal  branch. 
Malar  branch. 

Infraorbital,  infraorbital  plexus. 
Cervico-facial  division,  810-11.     (792) 
Buccal  branch. 
Supramandibular  branch. 
Inframandibular  branch  (distribution  shown  later). 


Nerve-supply.  Action.     Relations. 

Nerve-supply.  Action. 

Nerve-supply.  Action. 

Nerve-supply.  Action. 


Relations. 
Relations. 
Relations. 


1 8  OUTLINES  OF  AN  A  TO  My. 

Fifth  nerve  : — (Sensory  branches). 
Ophthalmic  division  :  — 

Infratrochlear  nerve,  797.     (779) 

Terminal  or  anterior  branch — of  nasal  nerve,  797.     (779) 
Branches  from  superior  maxillary  division,  799-800.     (780-1) 
Malar  branch. 
Labial  branches. 
Nasal  branches. 
Palpebral  branches. 
Infraorbital  plexus. 

Branches  from  the  mandibular  division  : — 
Long  buccal  nerve,  803.     (784-5) 
Mental  branch,  804.     (786) 

Mental  branch  of  mandibular  artery,  525.     (516-17) 
Facial  portion  of  the  facial  artery,  515-16.     (507) 

Branches  of  the  facial  artery  on  the  face,  517-18.     (509-10) 
Outer  or  concave  side  : — 
Masseteric  branches. 
Buccal. 
Inner  or  convex  side  :  — 

Inferior  labial  artery. 
Inferior  coronary  artery. 
Superior  coronary  artery. 

Arteria  septum  narium. 
Lateral  nasal  artery. 
Angular  artery. 

Angular  vein,  650;  Fig.  385.     (636-7) 
Tributaries:  — 

Superior  lateral  nasal  veins. 
Palpebral  veins. 

Facial  vein,  650-1 ;  Fig.  385.     (637-8) 
Tributaries:  — 

On  the  inner  side  :  — 

Inferior  lateral  nasal  vein. 
Superior  labial  or  coronary. 
Inferior  labial. 
On  the  outer  side  : — 

Inferior  palpebral  veins. 
Anterior  internal  maxillary. 
Buccal. 

Anterior  parotid. 
Masseteric. 

Temporal  artery  or  superficial  temporal  artery,  521.     (513) 
Branches  of  the  temporal  artery,  522.     (513) 
Parotid  branches. 
Articular  branches. 
Masseteric. 

Auricular  or  anterior  auricular  branches. 
Transverse  facial. 

Common  temporal  vein,  652  ;  Fig.  385.      (639-40) 
Tributaries : — 

Transverse  facial  vein.     Articular  veins. 
Parotid  veins.     Masseteric  veins. 
Anterior  auricular  veins. 

Temporo-maxillary  vein,  653;  Fig.  385.     (640) 
Auriculo-temporal  nerve,  803.     (785) 

Superficial  lymphatic  vessels  of  the  face,  689  ;  Fig  398.     (674) 
Parotid  lymphatic  glands,  689-90.     (674) 
Buccal  lymphatic  glands,  690.     (675) 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  19 

Remove  the  muscles  of  the  nose  and  expose  the  nasal  cartilages. 

The  cartilages,  927-8  ;  Figs.  512-13-14.     (906-7) 

Superior  lateral.     Inferior  lateral.     Cartilage  of  the  septum. 
Also,  the  sesamoid  and  accessory  quadrate. 
Upper  lateral  cartilages. 
Lower  lateral  cartilages. 
Inner  plates. 
Outer  plates. 
Sesamoid. 

Accessory  quadrate. 
Septal  cartilage. 

Anterior  border. 

A  pad,  which  should  be  kept  properly  moistened  with  preservative  fluid,  should  be  placed  over  the 
orbit  and  face,  and  retained  in  place  by  a  bandage,  until  the  part  is  wanted  for  further  dissection. 

THE  EAR,  907.     (886) 

External  Ear: — Pinna  and  external  auditory  meatus. 

Middle  Ear,  or  tympanum,  with  the  Eustachian  tube. 

Internal  Ear,  which  includes  the  osseous  labyrinth,  within  which  is  placed  the 

membranous  labyrinth. 

The  External  Ear,  907-8-9-10.     (886-7-8-9) 
Pinna,  or  auricle. 

Helix.     Lobule.     Concha.     Scaphoid  fossa. 

Antihelix.     Antitragus.     Triangular  fossa.     Tragus.     Antitragus. 

The  skin  should  be  removed  from  the  surface  of  the  entire  auricle,  exposing  the  structures  underneath. 

Cartilaginous  framework.     Lobule.     Fissures  of  Santorini. 
Ligaments  :  — 

Anterior  ligament. 
Posterior. 

Muscles : — Extrinsic  muscles  (attollens,  attrahens,  and  retrahens  aurem). 
Intrinsic  muscles  : — Helicis  major.     Helicis  minor. 

Tragicus.    Antitragicus.    Transversus  auris. 
Obliquus  auris. 
Vessels  : — 

Arteries  : — Posterior  auricular.     Anterior  auricular. 
Veins.  Also,  Veins  of  the  ear,  663.     (650) 

Nerves  : — Great  auricular.     Posterior  auricular  of  the  facial. 
Auricular  branch  of  the  pneumogastric. 
Auriculo  temporal.     Small  occipital. 
(External  Auditory  Meatus.) 

The  pinna  should  be  left  in  place.  The  external  auditory  canal  will  be  more  fully  considered  at  a  later 
period,  in  connection  with  the  middle  ear. 

THE  NECK. 

Superficial  Structures. 

Landmarks  in  the  middle  line,  1124-5-6.     (1101-2-3) 

Continue  the  median  incision  to  the  sternum  and  make  a  transverse  incision  along  the  anterior  border 
of  the  clavicle  to  the  outer  end.  Turn  the  skin  outward  and  backward  from  the  median  line,  exposing 
the  superficial  fascia.  The  platysma  should  then  be  exposed. 

Superficial  fascia,  452.     (447) 

Platysma  myoides,  452-3-4.     (447-8-9) 

(Origin.)    Insertion.     Structure.     Nerve-supply.    Action.     Relations.     Variations. 

Beginning  at  the  mandible,  carefully  reflect  the  platysma  downward  to  the  clavicle  and  remove  the 
cervical  portion,  dividing  it  about  half-an-inch  above  the  clavicle.  In  reflecting  the  platysma  great 
care  must  be  exercised  not  to  remove  or  injure  the  nerves  or  veins  immediately  beneath  it. 

External  jugular  vein,  654.     (641) 

Chief  variations  of  the  external  jugular  vein. 


20  OUTLINES  OF  ANATOMY. 

External  jugular  vein  : — 

Tributaries  and  communications,  Fig.  385. 
Posterior  external  jugular. 
Transverse  cervical  and  suprascapular. 
Sometimes — the  anterior  jugular. 
Posterior  external  jugular  vein. 
Vertical  set  of  superficial  cervical  glands  of  the  neck,  or  superficial  cervical  chain, 

691.     (675-6) 

Anterior  jugular  vein,  655.     (642) 
Cervical  plexus : — 

Upper  four  cervical  nerves,  829.     (809-10) 
Superficial  Branches,  829-30-1.     (810-11-12) 
Ascending  branches  : — 
Lesser  occipital  nerve. 
Auricular  branch. 
Mastoid  branch. 
Occipital  branch. 
Great  auricular  nerve: — 
Mastoid  branch. 
Auricular  branches. 
Facial  branches. 
Transverse  branch  : — 

Superficial  cervical  nerve. 
Descending  branches: — 
Suprasternal  twigs. 
Supraclavicular  nerves. 
Supra-acromial  branches. 

Inframandibular  branch — of  the  facial  nerve,  8n  ;  Fig.  449.     (792) 
Read: — The  cervical  fascia.     Prevertebral  fascia,  472-3.     (466) 
Deep  cervical  fascia,  1130-1-2-3-4.     (1107-8-9-10-11) 
Arrangement  above  the  hyoid  bone  :  — 
Superficial. 
Deeper  layer. 
Below  the  hyoid  bone  : — 

Four  layers: — Superficial  or  subcutaneous. 
Sterno-clavicular. 
Tracheal. 
Prevertebral. 
Traced  vertically:  — 

At  the  level  of  the  top  of  the  sternum  :  — 
Superficial. 
Sterno-clavicular. 
Tracheal. 
Prevertebral. 

At  the  level  of  the  clavicle  :  — 
Subcutaneous. 
Sterno-clavicular. 
Uses  and  important  points: — 

(A)  Forms  certain  definitely  enclosed  spaces. 

(B)  Sheaths  of  canals. 

(C)  Helps  to  resist  atmospheric  pressure. 

(D)  Action  on  the  pericardium,  prevents  pressure  of  the  lungs  on 

the  heart. 

The  relations  of  the  deep  fascia  should  be  remembered  and  recalled  as  the 
structures  enclosed  by  it  are  successively  exposed  during  the  process  of  the 
dissection. 

Reflect  the  fascia  and  expose  the  sterno-cleido  mastoid  in  place.     The  external  jugular  vein  should  be 
preserved. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  21 

Sterno-cleido-mastoid,  473-4-5.     (467-8)     Also,  1126-7.     (IIO3) 

Origin;  sternal  head,  clavicular  head.     Insertion.     Structure.     Nerve-supply. 
Action.     Relations.     Variations. 

The  sterno-cleido-mastoid  divides  the  side  of  the  neck  into  an  anterior  and  a  posterior 
triangular  space.  The  boundaries  of  the  posterior  space  are  formed  by  the  clavicle 
below,  the  sterno-cleido-mastoid  in  front,  the  trapezius  behind,  and  the  occiput  above. 
The  posterior  belly  of  the  omo-hyoid  crosses  the  space  about  an  inch  above  the  clavicle, 
and  divides  it  into  an  upper  or  occipital,  and  a  lower  or  subclavian  triangle.  The  floor 
of  the  space  is  formed  from  above  downward  by  the  splenius,  levator  anguli  scapulce, 
scalenus  medius,  and posticus. 

Posterior  Triangle,  1129.     (1106) 

Carefully  remove  the  fascia  and  dissect  out  the  connective  tissue  and  fat,  exposing  the  structures  in  the 
posterior  triangular  space. 

Omo-hyoid,  476  ;  Fig.  314.     (469) 

(Origin.     Insertion.     Structure.     Relations.) 
Spinal  accessory  nerve,  1130.     (1106-7) 
Branches  to  the  trapezius,  831.     (812) 
Nerves  to  the  levator  anguli  scapulae,  831.     (812) 
Third  portion  of  the  subclavian  artery,  538-9.     (529-30) 
Relations  : — In  front. 

Behind. 

Below. 

Above. 

The  outer  portion  of  the  transverse  cervical  and  suprascapular  arteries  will  be  exposed,  the  origin  of  the 
vessels  will  be  shown  later. 

Transverse  cervical  or  transversalis  colli  artery,  546-7.     (537) 
Suprascapular  or  transversalis  humeri,  546.     (536) 

Branches  of  the  suprascapular  :  — 

(i),  (2),  (3),  (4). 
Veins  :  — 

External  jugular  vein,  1130.     (1106) 

Suprascapular  veins,  654.     (641) 

Transverse  cervical  veins,  654.    (642) 

Subclavian  vein,  682-3.     (668) 

Tributaries. 
Anterior  Triangular  Space. 

The  muscles  forming  the  boundaries  of  the  smaller  triangles  should  first  be  exposed.  Remove 
the  fascia  forming  the  sheaths  of  the  muscles  and  dissect  out  the  fat  and  connective  tissue.  The  small 
nerves,  the  arterial  branches,  and  the  venous  tributaries  must  all  be  carefully  preserved.  Beginning  at 
the  symphysis,  expose  the  anterior  belly  of  the  digastric;  then  the  posterior  belly  anterior  to  the  border 
of  the  sterno-mastoid,  removing  the  portion  of  the  parotid  gland  superficial  to  it.  The  process  of  fascia 
binding  the  tendon  to  the  hyoid  bone  should  be  preserved.  In  exposing  the  omo-hyoid  avoid  injury  to 
the  branches  of  the  ansa  hypoglossi  which  pass  to  it. 

Digastric,  478-9;  Fig.  314.     (471-2) 

Origin  :  anterior  belly  (posterior  belly).     Insertion.     Structure. 

Nerve-supply.     Action.     Relations.      Variations. 
Stylo-hyoid,  479  ;  Fig.  314.     (472) 

Origin.     Insertion.     Structure.     Nerve-supply.    Action.    Relations.    Variations. 
Omo-hyoid,  476  ;  Fig.  314.     (469-70) 

(Origin.)    Insertion.   Structure.    Nerve-supply.    Action.    Relations.   Variations. 
Anterior  triangle,  1127-8-9.     (1104-5-6) 

Subdivided  into  three  triangles  : — 

Submaxillary  or  supra-hyoid  triangle. 
Superior  carotid  triangle. 
Inferior  carotid  or  tracheal  triangle. 

Before  continuing  the  dissection  the  student  requires  some  preliminary  knowledge  of  the 
structures  in  the  anterior  triangle,  their  position,  relations,  etc.  The  following  general 
description  {modified  by  Cunningham}  should  be  carefully  studied. 


22 


OUTLINES  OF  ANATOMY. 


General  Description. 

Inferior  Carotid  or   Tracheal    Triangle. — As  this   triangle  is  gradually 
opened  up  the  following  structures  will  come  into  view  :  — 

1.  The  sterno-hyoid  and  sterno-thyroid  muscles. 

2.  The  branches  from  the  ansa  hypoglossi  to  these  muscles. 

3.  The  external  laryngeal  nerve. 

4.  The  superior  thyroid  artery. 

5.  The  greater  part  of  the  larynx,  the  thyroid  body,  and  the  trachea. 

6.  The  oesophagus  on  the  left  side. 

7.  The  recurrent  laryngeal  nerve. 

When  the  fascia  is  removed  from  this  part  of  the  anterior  triangle,  the  only  struc- 
tures which  are  seen  within  its  limits  are  the  sterno-hyoid  and  sterno-thyroid  muscles. 
As  the  dissection  is  proceeded  with,  however,  the  large  nerve  of  supply  for  these 
muscles,  which  comes  from  the  ansa  hypoglossi,  will  be  found  lying  near  the  outer 
border  of  the  sterno-thyroid  and  breaking  up  into  numerous  twigs.  Toward  the 
upper  part  of  the  space  the  superior  thyroid  artery  will  be  noticed  passing  downward 
under  cover  of  the  omo-hyoid,  sterno-thyroid,  and  sterno-hyoid  muscles  to  reach 
the  thyroid  body.  At  a  slightly  higher  level  than  this  artery,  the  external  laryngeal 
nerve  runs  forward  to  end  in  the  crico-thyroid  muscle.  Under  cover  of  the  sterno- 
hyoid  and  sterno-thyroid  muscles  will  be  observed  the  larynx,  the  isthmus  and  a 
considerable  part  of  the  lateral  lobe  of  the  thyroid  body,  and  the  trachea.  The 
recurrent  laryngeal  nerve  lies  deeply.  It  will  be  found  in  the  interval  between  the 
gullet  and  the  trachea.  As  the  oesophagus  inclines  to  the  left  behind  the  trachea,  it 
follows  that  it  is  only  seen,  when  in  its  natural  position,  in  the  left  inferior  carotid 
or  tracheal  triangle. 

Superior  Carotid  Triangle. — During  the  dissection  of  the  superior  carotid 
triangle  the  following  parts  are  displayed: — 

1.  Common  carotid  dividing  into  external  and  internal  carotid  arteries. 

2.  Superior  thyroid. 

3.  Lingual.  j_  Branches  of  the  external  carotid. 

4.  Facial. 

5.  Occipital. 


Arteries.  \ 


Veins. 


6.  Ascending  pharyngeal. 

7.  Hyoid.  -I 

8.  Sterno-mastoid.         >  Branches  of  the  superior  thyroid. 

9.  Superior  laryngeal.  J 

[  10.  Sterno-mastoid  branch  of  the  occipital. 

f    i.  Internal  jugular. 

|     2.  Facial. 


Crossing  the  space  obliquely. 


3.  Anterior  temporo-maxillary.       Tributaries  of  the  internal  jugular. 

4.  Lingual. 

5.  Superior  thyroid. 

1.  Hypoglossal.      Crossing  the  space  in  a  transverse  direction. 

2.  Descendens  hypoglossi. 

3.  Nerve  to  thyro-hyoid. 

4.  Internal  laryngeal. 

5.  External  laryngeal. 

6.  Spinal  accessory. 

'.,    .-      \  Descending  vertically. 
8.  Sympathetic,  j  } 

Intercarotic  body. 

Portion  of  the  larynx  and  pharynx. 

Greater  cornu  of  the  hyoid  bone. 

Lymphatic  vessels  and  glands. 

This  subdivision  of  the  anterior  triangle,  when  opened  up,  contains  portions  of  each 
of  the  three  carotid  arteries.  It  is  well,  however,  that  the  dissector  should  clearly 
understand  that  it  is  only  after  the  parts  are  relaxed  by  dissection  that  these  vessels 
come  to  lie  within  the  space.  When  the  fascia  and  platysma  are  in  position  they 
are  completely  overlapped  by  the  sterno-mastoid  muscle.  The  common  carotid 


r 


Nerves.  \ 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  23 

artery  is  enveloped  along  with  the  internal  jugular  vein  and  the  vagus  nerve  in  a 
common  sheath  of  fascia.  The  carotid  sheath  should  be  slit  open,  care  being  taken 
of  the  descendens  hypoglossi  nerve,  which  also  descends  obliquely  within  it.  The 
intimate  connection  which  this  sheath  presents  with  the  prevertebral  layer  of  fascia 
can  now  be  made  out.  The  common  carotid  usually  bifurcates  opposite  to  the 
upper  border  of  the  thyroid  cartilage.  Observe  that  the  internal  carotid  at  first  lies 
behind,  and  to  the  outer  side  of  the  external  carotid.  Upon  the  coats  of  these  vessels 
numerous  sympathetic  twigs  ramify,  and,  at  the  point  of  bifurcation  of  the  common 
carotid,  a  small  oval  body,  termed  the  intercarotic  body,  will  be  found  closely  applied 
to  the  deep  surface  of  the  vessel.  The  branches  of  the  external  carotid  which  take 
origin  in  the  area  of  this  triangle  run  for  only  a  very  short  part  of  their  course  within 
it.  Three  branches  will  be  noticed  springing  from  the  anterior  aspect  of  the  external 
carotid.  Named  from  below  upward  these  are:  (i)  the  superior  thyroid,  which, 
after  having  given  off  its  hyoid,  superior  laryngeal,  and  sterno-mastoid  branches, 
disappears  under  cover  of  the  omo-hyoid  muscle,  and  enters  the  inferior  carotid 
triangle;  (2)  the  lingual,  which  leaves  the  space  by  passing  under  cover  of  the 
digastric  and  stylo-hyoid  muscles ;  and  (3)  the  facial,  which  ascends  under  the 
same  muscles  to  gain  the  digastric  triangle.  The  occipital  artery  commonly  springs 
from  the  posterior  aspect  of  the  external  carotid  close  to  the  lower  border  of  the 
digastric,  and  soon  quits  the  space  by  running  upward  and  backward  under  cover 
of  the  sterno-mastoid  muscle.  Its  sterno-mastoid  branch  comes  off  as  it  leaves  the 
triangle,  and  accompanies  the  spinal  accessory  nerve.  The  ascending  pharyngeal 
artery  will  be  found  by  separating  the  external  and  internal  arteries  from  each  other, 
and  dissecting  between  them.  It  springs  from  the  posterior  aspect  of  the  former 
about  half-an-inch  above  its  origin,  and  then  takes  a  vertical  course  upward  on  the 
prevertebral  muscles. 

The  internal  jugular  vein  lies  close  to  the  outer  side  of  the  common  carotid 
artery,  and  is  included  within  the  same  fascial  sheath.  Several  tributaries  join  it  as  it 
passes  through  this  space.  The  most  conspicuous  of  these  is  the  common  facial  vein, 
which  is  formed  by  the  union  of  the  facial  vein  and  the  anterior  division  of  the  tem- 
poro-maxillary  vein. 

The  nerves  which  are  brought  into  view  as  the  carotid  triangle  is  gradually 
opened  up  are  very  numerous,  but  they  can  be  classified  according  to  the  direction 
which  they  take  through  the  space.  One  large  nerve,  the  hypoglossal,  takes  a  more  or 
less  transverse  course  across  the  upper  part  of  the  space.  It  forms  a  loop  across  this 
part  of  the  neck  immediately  below  the  lower  margin  of  the  digastric  muscle.  Two 
descend  vertically, — viz.,  the  vagus  and  the  gangliated  cord  of  the  sympathetic.  The 
vagus  lies  in  the  posterior  part  of  the  carotid  sheath  between  the  common  carotid 
artery  and  the  internal  jugular  vein.  The  sympathetic  cord is  imbedded  in  the  poste- 
rior wall  of  the  carotid  sheath.  The  remaining  five  nerves  traverse  the  triangle 
obliquely.  Four  -run  from  above  downward  and  forward,  viz.,  the  descendens 
hypoglossi,  the  thyro-hyoid,  the  internal  and  external  laryngeal  nerves ;  and  one — 
the  spinal  accessory — is  directed  from  above  downward  and  backward. 

The  descendens  hypoglossi  springs  from  the  hypoglossal  nerve  as  it  hooks  round 
the  occipital  artery  and  descends  within  the  carotid  sheath.  It  is  joined  at  the  upper 
border  of  the  omo-hyoid  by  one  or  two  branches  from  the  cervical  plexus,  and  in  this 
manner  the  ansa  hypoglossi  is  formed.  The  thyro  hyoid  is  a  minute  nerve  which 
arises  from  the  hypoglossal  nerve  before  it  disappears  under  cover  of  the  posterior 
belly  of  the  digastric.  The  internal  laryngeal  nerve  descends  behind  the  carotid 
vessels.  It  will  be  readily  found,  with  the  corresponding  artery,  in  the  interval 
between  the  hyoid  bone  and  upper  border  of  the  thyroid  cartilage.  It  enters  the 
larynx  by  piercing  the  thyro-hyoid  membrane.  The  external  laryngeal  nerve,  a 
branch  of  the  preceding,  is  a  much  smaller  twig.  It  leaves  the  space  by  passing 
under  cover  of  the  depressor  muscles  of  the  larynx  and  hyoid  bone.  The  spinal  ac- 
cessory nerve  is  placed  high  up  in  the  interval  between  the  digastric  and  the  sterno- 
mastoid  muscles.  It  soon  disappears  by  sinking  into  the  substance  of  the  sterno- 
mastoid. 

The  Submaxillary  or  Supra-hyoid  Triangle  may  be  divided  very  con- 
veniently into  an  anterior  and  posterior  part  by  the  stylo-maxillary  ligament  and  a 


OUTLINES  OF  ANATOMY. 


line  drawn  downward  from  it.  The  portion  in  front  has  a  distinct  floor,  composed,  in 
great  part,  by  the  mylo-hyoid  muscle,  and  behind  this  by  a  portion  of  the  hyo- 
glossus  muscle. 

The  parts  exposed  during  the  dissection   of  the  digastric  space  may  be  classified 
according  to  the  subdivision  in  which  they  lie  : — 


ANTERIOR  PART. 


1.  Submaxillary  gland. 

2.  Facial  artery  and  vein. 

3.  Branches  from  -\  a.  Ascending  palatine. 

facial   artery  f  b.  Tonsillitic. 
in   this   part  f  c.  Submaxillary. 
of  its  course.  )  d.  Submental. 

4.  Hypoglossal  nerve. 

5.  Mylo-hyoid  nerve. 

6.  Mylo-hyoid  artery. 

7.  Lymphatic  glands. 


POSTERIOR  PART. 


1.  Portion  of  the  parotid  gland. 

2.  External  carotid  artery. 

3.  Posterior  auricular  artery. 


The  most  conspicuous  object  in  the  fore  part  of  the  digastric  triangle  is  the  sub- 
maxillary  gland.  The  facial  artery  passes  upward  and  forward  in  the  midst  of  this 
gland,  whilst  the  facial  vein  lies  superficial  to  it.  But  whilst  the  facial  artery  runs 
through  the  gland,  the  dissector  should  note  that  it  can  be  separated  from  it  with- 
out any  laceration  of  the  gland  lobules.  The  gland  is,  as  it  were,  wrapped  round  it, 
so  that,  although  at  first  sight  the  artery  seems  to  pierce  it,  it  is  in  reality  merely 
contained  in  a  deep  furrow  in  its  substance.  Before  entering  the  gland,  the  facial 
artery  gives  off  its  tonsillitic  and  ascending  palatine  branches,  whilst  its  submental 
and  Submaxillary  branches  arise  within  the  gland.  The  submental  artery  runs  for- 
ward toward  the  chin.  The  mylo-hyoid  nerve  and  artery  will  be  seen  passing  for- 
ward and  downward  upon  the  mylo-hyoid  muscle  under  cover  of  the  Submaxillary 
gland.  The  twigs  of  the  nerve  to  the  muscle  of  the  same  name  and  to  the  anterior 
belly  of  the  digastric  should  be  followed  out.  Only  a  very  small  part  of  the  hypo- 
glossal  nerve  is  seen  in  this  space.  It  lies  upon  the  hyoglossus  muscle  immediately 
above  the  hyoid  bone,  and  disappears  under  cover  of  the  posterior  border  of  the 
mylo-hyoid  muscle.  Numerous  small  lymphatic  glands  lie  under  shelter  of  the  base 
of  the  lower  jaw. 

The  external  carotid  artery  enters  the  posterior  part  of  the  digastric  triangle. 
Here  it  lies  under  cover  of  the  lower  part  of  the  parotid  gland,  and  gives  off  its 
posterior  auricular  branch,  which  passes  upward  and  backward  along  the  upper 
border  of  the  posterior  belly  of  the  digastric  muscle. 

Middle  Line  of  the  Neck. — Before  the  parts  are  further  disturbed  the  dissector 
should  examine  the  structures  which  occupy  the  middle  line  of  the  neck — a  region, 
more  especially  in  its  lower  part,  of  the  highest  importance  and  interest  to 
the  surgeon.  The  middle  line  of  the  neck  may  be  divided  by  means  of  the  hyoid 
bone  into  an  upper  supra-hyoid  and  a  lower  infra-hyoid  portion. 

In  the  supra-hyoid  part  are  found  structures  which  are  concerned  in  the  construc- 
tion of  the  floor  of  the  mouth.  The  student  has  already  noticed  that  the  fatty 
superficial  fascia  is  more  fully  developed  here  than  elsewhere  in  the  neck,  and  that 
the  anterior  margins  of  the  two  platysma  muscles  meet  in  the  mesial  plane  about  half- 
an-inch  or  so  below  the  chin.  Above  this  point  their  fibres  decussate.  In  the  pres- 
ent condition  of  parts  the  two  anterior  bellies  of  the  digastric  muscles  are  observed 
attached  to  the  mandible  on  either  side  of  the  symphysis.  From  this  they  descend 
toward  the  hyoid  bone,  and  diverge  slightly  from  each  other  so  as  to  leave  a  narrow 
triangular  space  between  them.  The  floor  of  this  space  is  formed  by  anterior  portions 
of  the  two  mylo-hyoid  muscles,  whilst  bisecting  the  triangle  in  the  mesial  plane  in 
the  fibrous  raphe,  into  which  these  muscles  are  inserted.  Not  unfrequently  the  inner 
margins  of  the  digastric  muscles  send  decussating  fibres  across  the  interval  between 
them. 

The  infra-hyoid  part  of  the  middle  line  of  the  neck  extends  from  the  hyoid  bone 


HEAD  AND  ANTERIOR   CERVICAL  STRUCTURES.  25 

to  the  upper  margin  of  the  manubrium  sterni.  Below  the  hyoid  bone  is  the  thyro- 
hyoid  membrane,  succeeded  by  the  thyroid  cartilage  with  its  (prominent  pomum 
Adami.  Then  comes  the  tense  crico-thyroid  membrane  and  the  cricoid  cartilage. 
Except  along  a  narrow  interval  on  either  side  of  the  mesial  plane,  these  structures 
are  covered  with  two  muscular  strata,  viz.,  a  superficial  layer  formed  by  the  sterno- 
hyoid  and  omo-hyoid,  which  lie  on  the  same  plane,  and  a  deeper  layer  formed  by 
the  sterno-thyroid  and  its  continuation  upward,  the  thyro-hyoid.  In  addition  to 
these  an  elongated  process  of  the  thyroid  gland  not  unfrequently  stretches  upward 
(usually  upon  the  left  side),  under  cover  of  the  sterno-hyoid.  If  this  be  present, 
it  will  in  all  probability  be  observed  to  be  attached  to  the  hyoid  bone  by  a  narrow 
muscular  band,  termed  the  le vator  glandulte  thyroidea.  The  divergent  inner  margins 
of  the  two  small  crico-thyroid  muscles,  as  they  extend  upward  and  outward  upon  the 
cricoid  cartilage  toward  the  lower  margin  of  the  thyroid  cartilage,  will  also  be  seen. 
Upon  the  crico-thyroid  membrane,  as  it  appears  between  these  muscles,  the  small 
crico-thyroid  artery  runs  transversely  inward. 

Below  the  cricoid  cartilage  the  dissector  comes  upon  the  trachea,  which  extends 
downward  through  the  remaining  portion  of  the  middle  of  the  neck.  As  the  tube 
descends  it  gradually  recedes  from  the  surface,  so  that  at  the  upper  margin  of  the 
sternum  it  lies  very  deeply.  The  length  of  this  portion  of  the  trachea  varies  with 
the  position  of  the  head.  When  the  chin  is  raised,  and  the  head  thrown  as  far  back 
as  possible,  about  two  inches  and  three-quarters  of  the  tube  will  be  found  between 
the  cricoid  cartilage  and  the  sternum  ;  when,  on  the  other  hand,  the  head  is  held  in 
its  usual  attitude,  the  length  of  the  cervical  part  of  the  trachea  is  diminished  by  fully 
three-quarters  of  an  inch.  These  measurements  must  be  regarded  as  merely  express- 
ing the  average  condition.  They  vary  considerably  in  different  individuals,  and  are 
much  influenced  by  differences  in  the  length  of  the  neck. 

The  dissector  must  study  carefully  the  parts  which  lie  superficial  to  the  trachea 
in  this  portion  of  its  course.  In  the  first  place,  examine  the  structures  which  are 
in  immediate  contact  with  it.  These  are  (i)  the  isthmus  of  the  thyroid  body;  (2) 
the  inferior  thyroid  veins;  (3)  at  the  root  of  the  neck,  the  innominate  artery  and 
the  left  innominate  vein  ;  (4)  the  thymus  body  in  young  children  ;  and  (5)  the  occa- 
sional thyroidea  ima  artery.  The  isthmus  of  the  thyroid  is  a  thin  band  of  thyroid 
substance  which  crosses  the  mesial  plane  upon  the  anterior  aspect  of  the  trachea.  As 
a  general  rule  it  covers  the  second,  third,  and  fourth  tracheal  rings,  so  that  only  one 
ring  is  left  exposed  between  its  upper  margin  and  the  cricoid  cartilage.  Almost  in- 
variably a  branch  of  the  superior  thyroid  artery  runs  along  the  upper  margin  of  the 
isthmus,  whilst  upon  its  anterior  surface  is  placed  a  plexiform  arrangement  of  small 
veins.  The  inferior  thyroid  veins  are  two  in  number  and  of  large  size.  They  are 
formed  by  several  tributaries  which  issue  from  the  lateral  lobes,  and  proceed  down- 
ward upon  the  front  of  the  trachea,  one  upon  either  side  of  the  mesial  plane.  They 
are  separated  from  each  other  by  a  narrow  interval,  and  immediately  below  the  isth- 
mus they  are  connected  by  a  plexus  of  small  veins  which  lies  in  front  of  the  trachea. 
An  additional  median  vein,  taking  origin  from  the  isthmus,  may  also  exist.  Close  to 
the  sternum  the  innominate  artery  will  be  observed  lying  upon  the  trachea,  and  slightly 
below  the  level  of  the  upper  border  of  the  bone  the  left  innominate  vein  crosses  it. 
The  thyroidea  ima  is  an  occasional  branch  of  the  innominate  artery.  When  present 
it  passes  vertically  upward  in  front  of  the  trachea  to  the  isthmus  of  the  thyroid  gland. 

The  parts  which  separate  the  trachea,  with  the  structures  in  immediate  relation 
to  its  anterior  aspect,  from  the  surface,  should  now  be  studied.  The  two  anterior 
jugular  veins  as  they  run  downward  in  the  superficial  fascia,  one  upon  either  side  of 
the  mesial  plane,  have  been  already  noticed  ;  also,  the  two  layers  of  the  deep  cervical 
fascia  close  to  the  upper  margin  of  the  sternum,  and  in  the  'interval  between  these 
the  cross  branch  connecting  the  two  anterior  jugular  veins.  Behind  the  fascial 
envelope  of  the  neck  come  the  two  muscular  strata  formed  by  the  sterno-hyoid  and 
the  sterno-thyroid  muscles.  The  inner  margins  of  the  sterno-hyoid  muscles  are 
almost  contiguous  above,  and  held  together  by  the  fascial  sheaths  which  enclose  them  ; 
below,  however,  they  diverge  slightly  from  each  other,  so  as  to  expose,  close  to  the 
sternum,  the  inner  margins  of  the  sterno-thyroid  muscles.  The  sterno-thyroid 
muscles,  in  contact  with  each  other  below,  gradually  separate  from  each  other  as  they 


26  OUTLINES  OF  ANATOMY. 

ascend.     A  narrow,  lozenge-shaped  space  is  thus  left  between  the  inner  borders  of 
these  muscles.     Over  this  area  the  trachea  is  not  covered  by  any  muscular  structure. 

SURGICAL  ANATOMY.-    (From  Cunningham.') 

The  principal  operations  which  are  performed  in  the  middle  line  of  the  neck  are  those  of  laryng- 
otomy  and  tracheotomy. 

In  laryngotomy,  an  opening  is  made  into  the  larynx.  This  can  most  readily  be  done  in  the  inter- 
val between  the  thyroid  and  cricoid  cartilages.  A  vertical  mesial  incision  through  the  integument  is 
made  over  this  interval.  The  crico-thyroid  membrane  is  thus  exposed,  and  is  divided  transversely  close 
to  the  upper  margin  of  the  cricoid  cartilage.  It  is  a  very  simple  proceeding,  and  one  which  is  attended 
with  little  or  no  danger  if  ordinary  care  be  taken.  The  crico-thyroid  membrane  is  divided  transversely, 
and  in  its  lower  part,  for  two  reasons,  viz.,  (i)  to  avoid  injury  to  the  crico-thyroid  artery,  which, 
although,  as  a  general  rule,  of  small  size  and  of  no  surgical  importance,  is  sometimes  large  enough  to 
give  rise  to  awkward  results  if  wounded  ;  and  (2)  to  place  the  opening  as  low  down  as  possible. 

Tracheotomy  is  a  more  serious  operation.  The  opening  into  the  trachea  may  be  made  above 
or  below  the  isthmus  of  the  thyroid  body.  The  high  operation  is  very  properly  preferred  by  the  sur- 
geon. Its  advantages  are  very  apparent:  here  the  trachea  lies  near  the  surface,  and  no  veins  of  any 
importance  are  met  with.  The  only  drawback  consists  in  the  small  portion  of  trachea  which  intervenes 
between  the  isthmus  and  the  cricoid  cartilage.  Still,  this  can  be  increased  by  pushing  down  the 
isthmus,  which,  within  certain  limits,  can  be  easily  dislodged  in  a  downward  direction.  Many  surgeons, 
indeed,  consider  that  the  wounding  of  the  isihmus  is  a  matter  of  comparatively  slight  importance.  The 
fact,  however,  that  a  large  branch  of  the  superior  thyroid  artery  is  generally  found  in  relation  to  its 
upper  border  should  make  the  operator  hesitate  before  having  recourse,  in  all  cases,  to  this  expedient 
for  gaining  additional  space.  In  the  child  it  is  frequently  necessary  to  combine  the  high  operation  of 
tracheotomy  with  that  of  laryngotomy — viz.,  by  cutting  through  the  cricoid  cartilage. 

The  low  operation  is  a  formidable  undertaking.  It  is  true  that  there  is  a  greater  length  of 
tube  to  be  operated  upon ;  but  this  is  situated  very  deeply,  and  the  surgeon  encounters  many  difficulties 
before  it  is  reached.  If  the  dissector  reflect  upon  the  structures  which  intervene  between  this  part  of 
the  trachea  and  the  surface,  he  will  fully  realize  this;  and  he  must  bear  in  mind  that  these  difficulties 
are  greatly  intensified  in  the  living  subject  by  the  engorged  state  of  the  veins  and  the  convulsive  move- 
ments of  the  windpipe  as  the  patient  struggles  for  breath.  In  the  child,  the  thymus  body  interposes  an 
additional  obstacle;  and  this,  combined  with  the  more  limited  space,  the  small  calibre  and  great 
mobility  of  the  trachea,  render  the  operation,  in  such  cases,  a  very  serious  responsibility.  In  the  low 
operation,  the  trachea  must  be  opened  in  an  upward  direction,  so  as  to  avoid  injury  to  the  innominate 
artery  and  left  innominate  vein,  which  are  placed  in  front  of  it  at  the  upper  margin  of  the  sternum. 

Dissection. 

"  Dissection. — The  numerous  and  diverse  structures  contained  within  the  anterior  triangle  must  now  be 
displayed.  The  dissection  should  be  carried  out  over  the  entire  area  at  once,  and  the  structures  found 
in  one  subdivision  followed  upward  or  downward,  as  the  case  may  be,  into  the  other  subdivisions  of  the 
space.  It  is  a  common  fault  with  dissectors  to  fail  to  open  up  the  digastric  triangle  until  the  two  lower 
triangles  have  been  fully  dissected.  Two  small  nerves  are  especially  liable  to  injury,  and  therefore 
should  be  secured  as  early  as  possible.  They  are  the  thyro-hyoid  branch  of  the  hypoglossal  nerve,  and 
the  external  laryngeal  nerve.  The  hypoglossal  nerve,  which  will  be  found  crossing  the  carotid  triangle 
at  the  lower  border  of  the  posterior  belly  of  the  digastric,  should  be  traced  forward  ;  as  it  approaches 
the  hyoid  bone,  its  minute  thyro-hyoid  branch  will  be  discovered,  leaving  its  lower  border  at  an  acute 
angle,  and  proceeding  downward  and  forward  to  reach  the  thyro-hyoid  muscle.  The  external  laryn- 
geal nerve  is  a  long,  slender  branch  which  occupies  a  deeper  plane.  To  expose  it  the  carotid  vessels 
should  be  pulled  outward  from  the  larynx,  and  the  loose  tissue  in  the  interval  thus  opened  up  divided 
carefully  in  an  oblique  direction  and  along  a  line  connecting  the  cricoid  cartilage  with  the  bifurcation 
of  the  common  carotid  artery.  The  nerve  will  be  found  as  it  passes  downward  and  forward  to  disappear 
under  cover  of  the  depressor  muscles  of  the  larynx.  It  will  be  traced  to  its  ultimate  distribution  at  a 
subsequent  stage  of  the  dissection."  (Cunningham.) 

Hypoglossal  nerve,  820-1.     (801-2) 

Descendens  hypoglossi : — 

Ansa  hypoglossi. 
Sterno-hyoid,  475-6.     (468-9) 

Origin.    Insertion.   Structure.    Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  sterno-hyoid  transversely  about  an  inch  above  the  sternum,  raise  the  upper  portion  as  far  as 
the  insertion,  reflect  the  lower  portion  to  the  origin.  Expose  the  sterno-thyroid  and  thyro-hyoid 
muscles,  then  replace  the  sterno-hyoid. 

Sterno-thyroid,  477.     (470) 

Origin.    Insertion.    Structure.     Nerve-supply.     Action.     Relations.     Variations. 
Thyro-hyoid,  477.     (470-1) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.    Relations.     Variations. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES. 


27 


Divide  the  sternal  origin  of  the  sterno-mastoid.  Remove  the  tissues  covering  the  stemo- clavicular  joint 
and  expose  the  ligaments.  The  clavicular  attachment  of  the  sterno-mastoid  should  be  preserved  until 
the  dissection  of  the  subclavian  and  carotid  arteries  is  completed,  and  their  relations  studied. 

Sterno-clavicular  articulation,  227-8-9-30.     (233-4-5-6) 
Class.  — Diarthrosis.     Subdi  v  ision .  — Arthrodia. 
Capsular  ligament : — 

Posterior  sterno-clavicular  ligament. 
Anterior  sterno-clavicular  ligament. 

Below.     Superior  portion. 
Interclavicular  ligament. 
Rhomboid  or  costo-clavicular  ligament. 

Remove  the  anterior  ligament  and   expose   the   interarticular   fibro-cartilage  within   the 
joint. 

Interarticular  fibro-cartilage. 

Synovial  membrane. 
Arterial  supply. 
Nerve-supply. 
Movements. 
Behind  the  sterno-clavicular  joint,  1127.     (1103-4) 

Carefully  divide  the  remaining  ligaments  of  the  sterno-clavicular  articulation,  and  draw  the  sternal  end 
of  the  clavicle  slightly  forward;  with  ihe  saw  divide  the  clavicle  by  an  oblique  incision  extending  from 
the  outer  margin  of  the  sterno-cleido-mastoid  to  the  lower  portion  of  the  sternal  extremity  of  the  bone. 
Raise  the  fragment  of  clavicle  with  the  attached  sterno-cleido  mastoid,  and,  carefully  separating  the 
muscle  from  the  structures  underneath,  turn  it  upward  to  its  insertion.  In  raising  the  muscle,  note  the 
vessels  and  nerves  entering  its  deep  surface.  The  sterno-mastoid  must  not  be  detached  at  its  insertion 
until  the  dissection  of  the  subclavian  and  carotid  vessels  is  completed.  When  these  vessels  are  exposed, 
replace  the  sterno  mastoid  in  position  while  studying  their  relations.  As  the  jugular  and  subclavian 
veins  lie  in  a  plane  superficial  to  the  arteries,  they  may  be  first  exposed,  and  then  pushed  aside  while 
the  more  important  vessels,  the  arterial  trunks,  are  being  displayed.  Beginning  above,  trace  the  ter- 
minal or  exposed  portion  of  the  tributaries  to  the  internal  jugular,  and  follow  the  internal  jugular  from 
the  posterior  belly  of  the  digastric  to  its  termination ;  the  upper  portion  of  the  vessel  will  be  exposed  at 
a  later  period  of  the  dissection. 

Facial  vein,  common  facial  vein,  650.     (637-8) 
Submental  vein,  651.     (638) 
Inferior  or  descending  palatine  vein,  651. 
Submaxillary  or  glandular  veins,  651. 
Communicating  branch,  or  anterior  division  of  the  temporo-maxillary  vein,  651. 

Chief  variations  in  the  facial  vein. 

Lingual  vein,  665-6.     (652) 
Superior  thyroid  vein,  666.      (652) 
Middle  thyroid  vein,  666.     (652) 
Internal  jugular  vein,  665.     (651—2) 
Tributaries. 

Expose  the  scaleni  muscles  and  the  subclavian  vessels.  Care  must  be  exercised  not  to  injure  the  small 
branches  of  the  cervical  or  the  brachial  plexus,  or  the  branches  of  the  subclavian  artery.  A  portion  of 
the  pleura  of  the  lung  will  also  be  exposed,  but  must  not  be  injured.  The  termination  of  the  thoracic 
duct  will  be  found  at  the  junction  of  the  subclavian  and  internal  jugular  veins. 

Scalenus  anticus,  484;  Fig.  316.     (476—7) 

Origin.  Insertion.  Structure.  Nerve-supply. 
Scalenus  medius,  484;  Fig.  316. 

Origin.  Insertion.  Structure.  Nerve-supply. 
Scalenus  posticus,  484-5.  (477) 

Origin.  Insertion.  Structure.  Nerve-supply. 
Variations  of  the  scaleni. 

Subclavian  vein,  682-3.     (668-9) 
Tributaries. 

Chief  variations  in  the  subclavian  vein. 
Cervical  portion  of  the  thoracic  duct,  699.     (683-4) 


Action.  Relations. 
Action.  Relations. 
Action.  Relations. 


28  OUTLINES  OF  ANATOMY. 

Right  lymphatic  duct,  688,  692-3.     (673,  677) 
Subclavian  artery,  536.     (527) 

First  portion  of  the  right  subclavian  artery,  537.     (528) 
Relations  : — In  front. 
Behind. 
Below. 
Branches. 

The  upper  or  cervical  part  of  the  first  portion  of  the  left  subclavian  artery  will  be  exposed.  The 
origin  from  the  aorta  will  be  shown  at  another  time.  The  relation  to  the  sterno-mastoid  should 
be  demonstrated  by  replacing  the  muscle  in  position.  The  right  subclavian  can  be  exposed  from 
its  origin. 

Left  subclavian  artery,  536-7.     (527-8) 
Relations: — In  front. 

Behind. 

Right  side. 

Left  side. 

Second  portion  of  the  subclavian  artery,  538.     (528) 
Relations: — In  front. 

Behind. 

Above. 

Below. 
Branch. 

Third  portion  of  the  subclavian  artery,  538-9.     (529-30) 
Relations: — In  front. 

Behind. 

Below. 

Above. 

Chief  Variations  in  the  Subclavian  Artery. 

Expose  the  branches  of  the  subclavian  artery,  and  trace  them  to  the  point  where  they  pass  into 
or  under  other  structures;  the  terminal  portion  of  such  branches  will  be  demonstrated  later  in  the 
process  of  the  dissection. 

Branches  of  the  subclavian  artery,  540.     (530) 
First  portion  : — Vertebral. 

Thyroid  axis. 

Internal  mammary. 

Second  portion  : — Superior  intercostal. 
Third  portion. 

Vertebral  artery,  540.     (530-1) 

The  first,  or  cervical  portion  : — 
In  front. 
Behind. 
Inner  side. 
Outer  side. 

Chief  Variations  of  the  Vertebral  Artery,  541.     {532) 

Vertebral  vein,  666.     (653) 

Tributaries  : — Anterior  vertebral  vein. 

Deep  cervical  vein,  652.     (639) 
Thyroid  axis,  545.     (535) 
Inferior  thyroid. 
Suprascapular. 
Transverse  cervical. 
Inferior  thyroid,  545-6.     (536) 

Branches: — Muscular  branches. 
Ascending  cervical. 

Muscular.     Spinal.     Phrenic. 
OEsophageal  branches. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES. 


29 


Inferior  Thyroid  Branches: — 

Tracheal  branches. 

•  Inferior  laryngeal  branch. 

Inferior  thyroid  veins,  666.     (652) 

Right  vein. 

Left  vein. 

Suprascapular  or  transversalis  humeri,  546.     (536) 
Suprascapular  veins,  654.     (641) 
Transverse  cervical  or  transversalis  colli,  546—7. 
Transverse  cervical  veins,  654.     (642) 
Internal  mammary  artery,  548.     (538) 

Cervical  portion. 

Superior  intercostal  artery,  550-1-2.     (540-1-2) 
Branches  : — Deep  cervical  branch  :  — 

(Muscular.       Anastomotic.       Vertebral    or 
spinal). 

First  intercostal  branch. 
Arteria  aberrans. 

The  superficial  branches  of  the  cervical  plexus  have  already  been  displayed ;  some  of  the  deep  branches 
may  now  be  exposed  ;  others  will  be  shown  later,  as  the  deeper  structures  are  dissected. 

Cervical  nerves,  828-9.     (809) 
Upper  four  nerves  :  — 

First  nerve.     Second  nerve.     Third  and  fourth  nerves. 
Cervical  plexus,  829.     (809-10) 

Upper  four  cervical  nerves. 

The  following  table  (from   Cunningham)   indicates  the  origin,  branches, 
and  distribution  of  the  cervical  nerves: — 


Superficial  or 
Cutaneous. 


I  Ascending. 
,  Transverse. 

[  Descending. 


f  Smail  occipital. 
(  Great  auricular. 

Superficial  cervical. 
(  Supraclavicular. 
-  Suprasternal. 
(^  Supra-acromial. 


From  ad. 

From  ad  and  3d. 

From  3d  and  4th. 


f  Muscular. 


Deep. 


I  Communicating. 


Deep  branches,  831-2.     (812-13) 
Xerve  to  sterno-mastoid. 


f  i.  To  rectus  capitis 

anticus  major. 

2.  To  rectus  capitis 

•                      • 

•  From  ist  and  2d. 

anticus  minor. 

3.  To  rectus  capitis 

lateralis. 

4.  To  sterno-mastoid. 

From  2d. 

5.  Communicantes         ) 
hypoglossi.  j 

From  2d  and  3d. 

6.  To  levator  anguli 

scapulae. 
7.  To  scalenus  medius.   j 

From  3d  and  4th. 

8.  To  trapezius.              j 

9.  Phrenic,  to  diaphragm.    From  4th  and  5th 

r  i.   To  hypoglossal.          ] 

From  ist. 

!2.  To  vagus.                    \ 

3.  To  sympathetic. 

From  ist,  zd,  3d, 
and  4th. 

!  4.  To  spinal  accessory.  • 

From  2d,  3d,  and 
4th. 

30  OUTLINES  OF  ANATOMY. 

Cervical  Nerves,  Deep  Branches: — 

Nerves  to  the  scalenus  rnedius. 
Nerves  to  the  levator  angulse  scapulae. 
Branches  to  the  trapezius. 
(Internal  branches) :  — 

Communicating  branches. 
Muscular  branches : — 

Branch  to  the  rectus  capitis  lateralis. 
Nerve  to  the  rectus  capitis  anticus  minor. 
Nerve  to  the  rectus  capitis  anticus  major. 
Nerve  to  the  longus  colli. 

,  f  Communicantes  hypoglossi,  ansa  hypoglossi. 
'  (  Phrenic  nerve. 

f  Communicans  hypoglossi  and  phrenic  nerves  should   be  traced ;   the  other 
branches  can  be  shown  in  the  dissection  of  the  deeper  structures. 

The  common  carotid  artery  and  its  divisions  should  now  be  exposed.  The  origin  and  thoracic  por- 
tion of  the  left  common  carotid  will  be  shown  at  another  time.  The  origin  of  the  branches  of  the 
external  carotid  should  be  exposed,  and  the  branches  should  be  traced  to  the  point  where  they  pass 
into  or  under  other  structures.  The  terminal  distribution  of  such  branches  will  be  developed  later  in 
the  dissection.  The  pneumogastric  nerve  and  its  branches  will  be  considered  in  the  deep  dissection  of 
the  neck ;  the  branches  must  be  carefully  preserved. 

Common  carotid  arteries,  504-5.     (496-7) 
External  carotid. 
Internal  carotid. 

(Thoracic  portion  of  the  left  common  carotid  artery),  505.     (497) 
Common  carotid  artery  in  the  neck,  506-7-8-9.     (498-9-500-1) 

When  the  artery  and  its  divisions  have  been  fully  exposed,  the  sterno-mastoid  should  be 
replaced  in  position  and  the  relations  carefully  studied. 

Relations: — In  front. 

Behind. 

Internally : — 

Ganglion  intercaroticum,  or  carotid  gland. 

Externally. 
Branches. 

Variations  of  the  Common  Carotid  Arteries. 
The  collateral  circulation. 

External  carotid  artery,  509-10.     (501-2) 
Relations: — In  front. 
Behind. 
Internally. 
Externally. 

Chief  Variations  of  the  External  Carotid  Artery. 

Branches  of  the  external  carotid,  510.     (502) 

Superior  thyroid  artery,  512-13.     (503-4-5) 
Branches  of  the  superior  thyroid  artery  : — 
Hyoid — or  infra-hyoid  branch. 
Sterno-mastoid — or  middle  mastoid  artery. 
Superior  laryngeal  artery. 
Crico-thyroid — or  inferior  laryngeal  branch. 
Lingual  artery,  513-14.     (5°5-6) 
First  or  oblique  portion  : — 
Hyoid,  or  supra-hyoid. 
Facial  artery,  515-16-17.     (507-8-9) 
Cervical  portion  : — 

Branches  of  the  facial  artery  in  the  neck  : — 
(Inferior  or  ascending  palatine.) 
(Tonsillar  branch.) 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  31 

Branches  of  the  Facial  Artery  in  the  Neck  :  — 
Glandular  or  submaxillary  branches. 
Muscular  branches. 
Submental  branch  :  — 

Branches  :  —  Muscular.     Perforating. 

Cutaneous.     Mental. 
Occipital  artery,  518.     (510-11) 
First  part  of  its  course. 

Sterno-mastoid  branch. 
Auricular  branch. 
Posterior  auricular  artery,  520-1.     (512-13) 

Branches  of  the  posterior  auricular  artery  :  — 
Parotid  branches. 
Muscular  branches. 
Stylo-mastoid  branch  :  — 

(Meatal.     Mastoid.     Stapedic.) 
(Tympanic.     Vestibular.     Terminal.) 
Ascending  pharyngeal  artery,  510.     (502) 
(Terminal  divisions  of  the  external  carotid  :  —  ) 
Temporal  artery,  521.     (513) 
Internal  maxillary  artery,  522.     (514) 
Deep  lymphatic  vessels  of  the  head  and  neck,  691.     (676) 
Deep  lymphatic  glands  of  the  neck,  692.     (677) 
Upper  set. 
Lower  deep  cervical  glands. 

Divide  the  sterno-thyroid  transversely  about  an  inch  above  the  sternum  ;  raise  the  upper  portion  to  the 
insertion,  exposing  the  thyroid  body  or  gland. 


The  thyroid  body  or  gland,  952-3-4-5. 
Lateral  lobes  ;  isthmus. 
Relations. 

Middle  or  pyramidal  process,  thyro-glossal  duct. 
Structure. 
Vessels  :  — 

Arteries. 

Veins. 
Nerves. 
Lymphatics  of  the  thyroid  body,  692.     (677) 

The  cervical  portions  of  the  trachea  and  oesophagus  may  be  exposed;  in  the  interval  between  them  will 
be  found  the  cervical  portion  of  the  recurrent  laryngeal  nerve.  The  cervical  portion  of  the  recurrent 
laryngeal  nerve  should  be  exposed  ;  the  origin  and  the  terminal  distribution  will  be  seen  later. 

The  trachea,  or  air  tube,  950—1.     (929) 

Relations  :  —  Cervical  portion. 

Inferior  or  recurrent  laryngeal  nerve,  818-19.     (799-800) 
Of  the  right  side. 
Left  side. 

CE-ophagus,  987-8.     (966) 
Relations  in  the  neck  :  — 
In  front. 
Behind. 

On  its  right  side. 
On  the  left  side. 
Lymphatics  of  the  upper  part  of  the  resophagus  and  trachea,  692.     (677) 

Temporal  and  Pterygo-maxillary  regions. 

Divide  the  nerves  and  vessels  crossing  the  masseter  near  its  posterior  border  and  throw  them  forward. 
Remove  the  fascia  and  expose  the  surface  of  the  muscle. 


32  OUTLINES  OF  ANATOMY. 

Muscles  of  mastication,  468.     (462) 

Temporal  fascia. 

Masseteric  fascia. 
Masseter,  469.     (462-3) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Divide  the  temporal  fascia  along  the  upper  border  of  the  zygoma,  reflect  it  upward  and  remove  it,  ex- 
posing the  upper  portion  of  the  temporal  muscle.  Saw  through  the  zygomatic  arch  at  the  anterior  and 
posterior  borders  of  the  masseter  and  turn  the  muscle  downward  to  its  insertion  ;  in  doing  this,  note 
the  vessels  and  nerves  entering  its  deep  surface,  then  divide  them  close  to  the  muscle.  The  insertion  of 
the  temporal  will  then  be  exposed. 

Temporal  muscle,  469-70.     (463-4) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

With  the  saw,  divide  the  coronoid  process  by  an  oblique  cut,  extending  from  the  centre  of  the  sigmoid 
notch  to  the  concavity  of  the  mandible,  see  Fig.  313,  p.  471.  (465).  Raise  the  coronoid  process 
with  the  attached  temporal  muscle,  separating  it  from  the  structures  immediately  subjacent.  Carefully 
reflect  the  muscle  upward  toward  the  insertion.  In  reflecting  the  muscle  note  the  vessels  and  nerves 
entering  its  deep  surface.  Trace  the  middle  and  deep  temporal  vessels,  and  the  deep  temporal  nerves  ; 
also  the  temporal  branch  of  the  temporo-malar  nerve.  To  expose  the  structures  in  the  pterygoid  region 
part  of  the  posterior  portion  of  the  mandible  must  be  removed.  Divide  the  neck  of  the  mandible  trans- 
versely; with  the  knife  handle  carefully  separate  the  structures  from  the  inner  surface  of  the  ramus  as  far 
down  as  the  mandibular  foramen  ;  having  determined  the  position  of  the  foramen,  divide  the  ramus  by  a 
horizontal  incision  just  above  that  point  and  remove  the  portion  of  bone  between  the  two  incisions. 
Dissect  out  the  fat  and  areolar  tissue,  exposing  the  vessels,  nerves,  and  muscles. 

Internal  maxillary  artery,  522-3.     (514-15) 
First  part  of  its  course. 
Second  part  of  its  course. 
Third  part  of  its  course. 
Branches  of  the  internal  maxillary,  523-4.     (515) 

From  the  first  part. 

From  the  second  part. 

(From  the  third  part.) 

Branches   of  the   First  Part  of  the   Internal  Maxillary    Artery,  524-5. 
(515-16-17} 

Deep  auricular. 

Tympanic  branch,  or  Glaserian  artery. 

Middle  or  great  meningeal. 

Mandibular  artery  :  — 

(Incisive.) 

(Mental.) 

Lingual  or  gustatory  branch. 

Mylo-hyoidean  branch. 

Small  meningeal. 

Branches  of  the  Second  Part  of  the  Internal  Maxillary  Artery,  526.     (5/7) 

Masseteric  branch. 

Posterior  deep  temporal. 

Internal  pterygoid  branches. 

External  pterygoid  branches. 

Buccal  branch. 

Anterior  deep  temporal  branch. 

But  one  branch  of  the  third  portion  of  the  internal  maxillary  artery  can  be  exposed  at  the  present  stage 
of  the  dissection — the  posterior  dental  or  alveolar  branch. 

Posterior  dental,  or  alveolar  branch,  526.     (517) 
Branches : — Antral. 

Dental. 

Alveolar,  or  gingival. 

Buccal. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  33 

Veins,  653.      (640) 

Pterygoid  plexus  : — 

Middle  meningeal.     Posterior  dental  vein.     Mandibular.     Masseteric. 
Buccal.     Pterygoid  veins.     Deep  temporal.     Spheno-palatine  vein. 
Supraorbital.     Superior  palatine.     Ophthalmic.     Vesalian  vein. 
Internal  maxillary  vein. 
Pterygoideus  externus,  470-1-2.     (464-5) 
Origin  : — Upper  head. 
Lower  head. 

Insertion  : — Upper  head. 
Lower  head. 

Structure.     Nerve-supply.     Action.     Relations.     Variations. 
The  temporo-mandibular  articulation,  189-90-1-2.     (198-9-200-1) 

Class  : — Diarlhrosis.     Subdivision  :  —  Ginglymo-Arthrodia. 


Capsular  ligament :  — 
Anterior  portion. 
Posterior  portion. 

External  portion,  or  external  lateral  ligament. 
Internal  portion,  or  short  internal  lateral  ligament. 


Remove  the  external  portion  of  the  capsular  ligament,  and  expose  the  interior  of  the  joint  and 
the  interanicular  cartilage. 

Interarticular  cartilage. 
Two  synovial  membranes. 
Spheno-mandibular  ligament. 
Stylo-mandibular  ligament. 
Arterial  supply. 
Nerves. 
Movements :  — 

Ginglymoid,  or  hinge  character. 

Horizontal  gliding  action. 

Oblique  rotary. 

Divide  the  ligaments  of  the  temporo-mandibular  articulation  and  throw  forward  the  articular  process, 
with  the  attached  insertions  of  the  external  pterygoid  ;  in  doing  this,  special  care  must  be  exercised  not 
to  injure  structures  immediately  internal  to  the  joint.  The  small  branches  of  the  first  portion  of  the 
internal  maxillary  artery  can  now  be  traced  to  the  base  of  the  skull.  The  mandibnlar  division  of  the 
fifth  nerve  should  be  exposed  and  its  branches  traced. 

Third  or  mandibular  division  of  the  fifth  nerve,  801—2—3—4.     (783—4—5—6) 
Recurrent  nerve. 
Xerve  to  the  internal  pterygoid. 
Anterior  portion  : — 
Temporal  nerves. 
Masseteric  nerve. 
Nerve  to  the  external  pterygoid. 
Long  buccal  nerve. 
Posterior  portion:  — 

Auriculo-temporal  nerve  : — 
Articular  branch. 
Nerves  to  the  meatus. 
Parotid  branches. 
Mandibular  nerve  : — 
Mylo-hyoid. 
(Alveolar  branches.) 
(Incisive  branch.) 
Lingual  nerve. 

Chorda  tympani,  808.     (790) 
Pterygoideus  intemus,  472.     (465-6) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 


34  OUTLINES  OF  ANATOMY. 

Lymphatics  from  the  temporal  and  zygomatic  fossse,  691.     (676) 

The  structures  in  the  submaxillary  or  supra-hyoid  triangle  will  now  be  exposed.  Divide  the  facial 
artery  and  vein  where  they  cross  the  mandible.  Draw  the  tongue  forward  and  stitch  it  to  the  nose. 
Divide  the  anterior  belly  of  the  digastric  at  its  origin  from  the  mandible  and  throw  it  back,  exposing 
the  mylo-hyoid. 

Submaxillary  or  Supra-hyoid  region. 

Submaxillary  lymphatic  glands,  690.     (675) 

Supra-hyoid. 

Lingual-glands,  692.     (677) 
Mylo-hyoid,  479—80.     (472—3) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.     Relations.    Variations. 

Divide  the  mylo-hyoid  at  its  origin,  beginning  at  the  outer  border;  reflect  the  muscle  inward  and 
downward  to  the  insertion,  detaching  it  along  the  median  raphe.  With  the  saw,  divide  the  mandible 
about  a  quarter  of  an  inch  external  to  the  symphysis.  Tilt  the  lateral  portion  of  the  mandible  upward 
from  the  lower  border  and  retain  it  in  that  position  while  the  structures  of  the  region  are  being  exposed. 
Care  must  be  used  not  to  injure  the  mucous  membrane  of  the  floor  of  the  mouth.  The  submaxillary 
gland  is  now  exposed,  with  the  surrounding  muscles  and  the  structures  crossing  them.  The  submandi- 
bular  ganglion  lies  between  the  submaxillary  gland  and  the  hyo-glossus  muscle  ;  it  can  be  readily  ex- 
posed by  carefully  turning  down  the  gland  from  its  upper  border  and  following  the  chorda  tympani  and 
the  branches  of  the  lingual  nerve  passing  to  it.  The  stylo-glossus,  hyo-glossus,  and  genio-hyoid 
muscles  will  be  exposed,  also  the  anterior  portion  of  the  genio-hyo-glossus. 

Submaxillary  gland,  984.     (963) 

Duct  of  the  submaxillary  gland. 

Arteries. 

Nerves. 
Sublingual  gland,  984-5.     (963) 

Duct  of  Rivini. 

Arteries. 

Nerves. 
Lingual  nerve,  804-5.     (786) 

Branches. 
Submandibular  ganglion,  805.     (787) 

Branches. 
Hypoglossal  nerve,  821-2.     (802) 

Nerve  to  the  genio-hyoid. 

True  hypoglossal  branches  : — 
Nerve  to  the  stylo-hyoid. 
Nerves  to  the  hyo-glossus. 
Nerves  to  the  genio-hyo-glossus. 
Stylo-glossus,  482-3.     (474-5) 

Origin.     Insertion.     Structure.      Nerve-supply.     Action.     Relations. 
Hyo-glossus,  481-2.     (474) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Genio-hyoid,  480.     (473) 

Origin.     Insertion.    Structure.     Nerve-supply.    Action.    Relations.   Variations. 

Divide  the  hyo-glossus  at  its  origin  ;  carefully  separate  it  from  the  subjacent  structures  ;  draw  it  from 
under  the  structures  crossing  its  surface;  throw  it  upward  and  expose  the  structures  beneath  it. 

Lingual  artery,  513-14-15.     (505-6) 
Second  part  of  its  course. 
Third  part  of  its  course. 
Branches  : — Dorsalis  linguae. 

Sublingual  artery  : — 

Artery  of  the  fraenum. 
Ranine  artery. 
Lingual  vein,  665-6.     (652) 
Genio-hyo-glossus,  481.     (473-4) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Divide  the  posterior  belly  of  the  digastric  at  its  origin  and  throw  it  downward ;  in  raising  the  muscle 
note  the  branch  of  the  facial  nerve  which  supplies  it,  also  the  branch  to  the  stylo-hyoid.  Divide  the 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  35 

external  carotid  just  below  its  termination ;  cut  its  posterior  branches  at  their  origin,  and  throw  the 
vessel  forward.  The  deep  structures  can  now  be  exposed. 

Nerve  to  the  posterior  belly  of  the  digastric,  809.     (790) 
Xerve  to  the  stylo-hyoid,  809.     (790) 
Stylo-pharyngeus,  987.     (965) 

Deep  Dissection  of  the  Neck. 

Note  the  position  of  the  glosso-pharyngeal  nerve  and  its  relation  to  the  stylo-pharyngeus  muscle.  Divide 
the  styloid  process  at  its  base  and  throw  it  forward  and  downward  with  its  attached  muscles.  Expose 
the  upper  part  of  the  internal  jugular  vein  ;  then  divide  the  vein  about  two  inches  below  its  commence- 
ment and  throw  it  upward.  Carefully  expose  the  internal  carotid  artery  and  the  nerves  in  relation 
with  it.  Small  nerve  branches  marked  ( — )  *,  can  only  be  demonstrated  by  a  special  dissection  on  a 
fresh  subject  and  need  not  be  looked  for. 

Internal  jugular  vein  ;  bulb,  665.     (651—2) 

Tributaries. 

Internal  carotid  artery,  528—9.     (519—20) 
The  cervical  portion  : — 
Relations : — Behind. 

Outer  side. 
Inner  side. 

Ascending  pharyngeal  artery,  510-11-12.     (502-3) 
Branches : — Prevertebral. 
Pharyngeal. 
Palatine. 
Meningeal. 

Glosso-pharyngeal  nerve,  814-15.     (795—6) 
"  From  its  superficial  origin." 
(Jugular  ganglion.)* 
(Petrous  ganglion.)* 
Branches: — (Meningeal  branches.)* 
(Tympanic  branch.)* 

Communicating  twigs : — 
(a),  (*),  (0,  (d\  (* 
(Communicating  branches.)* 

See — lingual  branch,  809.     (790) 
Muscular  branch. 
Pharyngeal  branches. 
Tonsillar  branches. 
Lingual  branches. 

The  cervical  portion  of  the  pneumogastric  may  now  be  traced  and  its  branches  followed. 

Pneumogastric  or  vagus  nerve,  815-16-17-18.     (798-9-800) 
"  From  its  superficial  origin." 
(Ganglion  of  the  root.)* 
Ganglion  of  the  trunk  : — 

Branches: — Communicating  branches  : — 

(a),  (b\  (0,  (</),  GO- 
Branches  of  distribution  : — 

(Meningeal  or  recurrent  branch.)* 
(Auricular  branch,  or  nerve  of  Arnold.)* 
Pharyngeal  branches. 
Superior  laryngeal  nerve  : — 
Internal  branch. 
External  laryngeal  branch. 
Cardiac  branches. 
Spinal  accessory  nerve,  820.     (801) 

"At  the  base  of  the  skull." 
Hypoglossal  nerve,  821.     (802) 

"  The  filaments  unite  to  form  two  fasciculi,  etc." 
Meningeal  branch.)* 


36  OUTLINES  OF  ANATOMY. 

Sympathetic  nerves,  863-4.     (843-4) 

Gangliated  cords  of  the  sympathetic,  864-5-6-7-8.     (844-5-6-7) 
Cervical  portion  of  the  gangliated  cord  :  — 

Superior  cervical  ganglion,  rami  communicantes. 
Branches: — Ascending  branch. 

(Carotid  plexus)  : — 

Tympanic  branch.     Great  deep  petrosal  nerve. 
Branches  to  the  Gasserian  ganglion. 
Branches  to  the  sixth  nerve. 
(Cavernous  plexus)  : — 

Communicating  branches  to  the    third,  fourth, 
and  ophthalmic  division  of  the  fifth  cranial  nerves. 
Sympathetic  root  of  the  lenticular  ganglion. 
Nervi  molles. 

Communicating  branches  to  the  cranial  nerves. 
Pharyngeal  branches. 
Superior  cervical  cardiac  nerve. 

Middle  cervical  ganglion  ;   rami  communicantes  ;  ansa  Vieussenii. 
Branches: — Branches  to  the  thyroid  body. 

Middle  cervical  nerve. 

Inferior  cervical  ganglion,  rami  communicantes. 
Branches: — Branches  to  the  vertebral  artery. 

Inferior  cardiac  nerve. 
Relations — of  the  pharynx,  987.     (965-6) 

Prevertebral  Region.     Articulations. 

Remove  the  sterno-mastoid,  sterno-hyoid,  sterno-thyroid,  and  the  thyroid  body.  The  structure  of  the 
pharynx  can  be  demonstrated  to  advantage  only  when  separated  from  the  spine  and  posterior  portion 
of  the  skull ;  it  is  therefore  necessary  to  divide  the  skull  and  remove  the  anterior  portion  with  the 
pharynx  attached.  Divide  the  trachea,  oesophagus,  and  recurrent  laryngeal  nerves  about  an  inch  below 
the  larynx  ;  cut  the  common  carotid  artery  about  an  inch  below  its  termination  ;  divide  the  vagus  and 
sympathetic  nerves  at  the  same  level.  Draw  the  trachea  and  oesophagus  forward,  carefully  separating 
the  pharyngeal  walls  from  their  prevertebral  attachment.  At  the  base  of  the  skull,  divide  the  perios- 
teum and  expose  the  basilar  process  between  the  pharynx  and  the  prevertebral  muscles;  with  the  chisel, 
divide  the  basilar  process  at  this  point,  driving  the  chisel  upward  through  the  bone.  With  a  narrow 
saw,  carry  a  cut  inward  on  each  side,  along  the  posterior  border  of  the  petrous  portion  of  the  temporal 
bone,  passing  just  behind  the  jugular  foramen,  then  curving  forward  on  its  inner  side  to  the  suture 
between  the  basilar  process  and  the  petrous  portion  of  the  temporal  bone,  joining  the  first  cut,  made 
with  the  chisel.  Great  care  must  be  exercised  not  to  injure  the  pharyngeal  wall.  The  pharynx  should 
be  wrapped  in  a  cloth,  moistened  with  preservative  fluid,  while  the  remaining  structures  of  the  pre- 
vertebral region  are  exposed. 

Longus  colli,  486-7.     (478) 
Vertical  portion  : — 
Origin. 
Insertion. 

Lower  oblique  portion  : — 
Origin. 
Insertion. 

Upper  oblique  portion  :  — 
Origin. 
Insertion. 

Structure.     Nerve-supply.     Action.     Relations. 
Rectus  capitis  anticus  major,  485.     (477) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Rectus  capitis  anticus  minor,  485-6.     (478) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Intertransversales,  449-50.     (445) 

Structure.     Nerve-supply.     Action.     Relations. 

Remove  the  muscles  covering  it  and  expose  the  vertebral  portion  of  the  vertebral  artery. 

Vertebral  artery : — 

Second  or  vertebral  portion,  540.     (532) 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  37 

Branches  of  the  second  or  vertebral  portion,  542. 
Lateral  spinal  branches. 
Muscular  branches. 

The  Ligaments  and  Joints  between  the  Skull  and  Spinal  Column,  and  between  the 
Atlas  and  Axis,  193-200.     (201-208) 

The  Articulation  of  the  Atlas  with  the  Occiput. 

Class: — Diarthrosis.     Subdivision  : — Ginglymo-Arthrodia. 
Anterior  occipito-atlantal  ligament. 
Posterior  occipito-atlantal  ligament. 
Capsular  ligaments. 

Anterior  oblique  or  lateral  occipito-atlantal  ligament. 
Synovial  membrane. 
Arterial  supply. 
Nerve-supply. 
Movements  : — Directly  lateral. 

Obliquely  lateral. 
The  Articulations  between  the  Atlas  and  Axis. 

•  j          T   -    .      (Class: — Diarthrosis. 

The  Lateral  Atlanto-axoidean  Joints.  \  c  ,  ,. 

J  (Subdivision: — Arthrodia. 

r~,      r*  -,          T   -    .    j  Class: — Diarthrosis. 

The  Central  Atlanto-axoidean  Joint.  \  -  ,  ,.  -  •  ™      ,    . , 

J  (  Subdivision  :  —  Trochoides. 

Anterior  atlanto-axoidean  ligament. 

Posterior  atlanto-axoidean  ligament. 
The  Lateral  Atlanto-axoidean  Joints:  — 

Capsular  ligaments. 

Synovial  sac. 
The  Central  Atlanto-axoidean  Joint : — 

Transverse  ligament.     Crucial  ligament. 

Atlanto-odontoid  capsular  ligament. 

Synovial  membranes. 
Arterial  supply. 
Nerve  supply. 
Movements. 
The  Ligaments  uniting  the  Occiput  and  Axis. 

Occipito-cervical  or  cervico-basilar  ligament. 
Lateral  occipito-odontoid  or  check  ligaments. 
Central  odontoid  or  suspensory  ligament. 

Dissection  of  the  Pharynx. 

The  dissection  of  the  pharynx  and  the  structures  of  the  anterior  portion  of  the  skull  will  now  be  con- 
tinued; first  examine  the  cavity  of  the  mouth,  and  the  palate,  through  the  buccal  orifice. 

The  mouth,  979-80.     (958-9) 
Fauces. 
Vestibule. 
Buccal  orifice  : — 

Upper  and  lower  lips  : — 

Lips. 
Cheeks. 
Gums. 

The  palate,  980.     (959) 
Hard  palate. 
Soft  palate  : — 
Uvula. 

Pillars  of  the  fauces  : — 
Anterior  pillar. 
Posterior  pillar. 
Tonsillar  recess. 
Isthmus  of  the  fauces. 
Anterior  surface  of  the  soft  palate. 


38  OUTLINES  OF  ANATOMY. 

Moderately  distend  the  pharynx  with  tow;   place  it  with  its  posterior  surface   uppermost,  and  demon- 
strate the  muscles  forming  its  wall. 

The  pharynx : — 

Pharyngeal  walls,  985.     (964) 

Veins  of  the  pharynx,  665.     (651) 
Muscles,  985-6-7.     (964-5) 

Muscular  coat : — Constrictor  muscles. 

Stylo-  and  palato-pharyngei. 
Inferior  constrictor. 
Middle  constrictor. 

Divide  the  internal  pterygoid  transversely  near  the  middle,  and  draw-aside  its 
upper  and  lower  portions  to  fully  expose  the  origin  of  the  superior  constrictor  and 
the  middle  portion  of  the  buccinator. 

Superior  constrictor.     Sinus  of  Morgagni. 

Note  the  continuity  of  the  superior  constrictor  with  the  middle  portion  of 
the  buccinator,  through  the  pterygo-mandibular  ligament. 

Buccinator,  462-4.     (457-8) 
Origin,  (2).     Relations. 
Stylo-pharyngeus,  987.     (965) 
(Palato-pharyngeus.) 
Pharyngeal  aponeurosis. 

Open  the  pharynx  by  a  median  incision  through  its  posterior  wall,  extending  from  the  base  of  the 
skull  to  the  commencement  of  the  resophagus  ;  at  the  base  of  the  skull  make  a  lateral  incision  each 
way  from  the  median  incision. 

The  pharynx,  985.     (964) 
Nasal  portion. 
Buccal  portion. 
Mucous  membrane. 
Interior  of  the  pharynx,  987.     (966) 
Pharyngeal  recess. 
Pharyngeal  bursa. 
Pharyngeal  tonsil. 
Eustachian  tube,  913.     (892) 
Cartilaginous  portion. 
Mucous  membrane. 

Lymphatics  of  the  pharynx,  692.     (676) 
Internal  maxillary,  or  deep  facial  glands,  692.     (677) 
Post-pharyngeal  gland. 

The  soft  palate  and  associated  parts  should  now  be  examined  from  behind. 

The  soft  palate,  980-1-2.     (959-60-61) 
Uvula. 
Pillars  of  the  fauces:  — 

Anterior  pillar. 

Posterior  pillar. 
Tonsillar  recess. 
Isthmus  of  the  fauces. 
Mucous  membrane  of  the  soft  palate. 

Strip  off  the  mucous  membrane  and  expose  the  muscles  of  the  soft  palate. 

Muscles : — 

Levator  palati. 

Azygos  uvulae. 

Palato  pharyngeus. 

Palato  glossus. 

Tensor  palati. 

Arterial  supply  of  the  soft  palate. 
Nerves  to  the  soft  palate. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  39 

Tonsils  : — 

Arteries  of  the  tonsil. 
Veins  of  the  tonsil. 
Nerves  of  the  tonsil. 

Beginning  at  the  angle  of  the  mouth,  make  an  incision  backward,  dividing  the  buccinator,  mucous 
membrane,  pterygo  maxillary  ligament,  and  the  superior  constrictor.  Wrap  the  anterior  portion  of  the 
skull  in  a  cloth  moistened  with  preservative  fluid  and  lay  it  aside  until  the  dissections  of  the  tongue 
and  the  larynx  are  completed.  The  tongue  will  be  examined  first. 

The  tongue,  921-2-3-4-5.     (900-1-2-4) 

Special  sense  of  taste.     Function  of  speech.     Mastication  and  deglutition. 
Dorsum.     Tip. 
Mucous  membrane : — 

Folds : — Glosso-epiglottidean. 
Fraenum  epiglottidis. 

Glosso-epiglottidean  pouch,  or  vallecula. 
Anterior  pillars  of  the  fauces. 
Fraenum  linguae. 

Median  raphe.     Foramen  caecum. 
Papillae  : — 

Circumvallate,  or  caliciform  papillae. 
Fungiform  papillae. 
Filiform,  or  conical  papillae. 
Lingual  glands. 
Gland  of  Xuhn. 
Lymphoid  tissue. 
Muscles: — 

Extrinsic  muscles. 
The  intrinsic  muscles  : — 
Lingualis  superior. 
Inferior  lingualis. 
Transverse  fibres. 
Vertical  fibres. 

Fibrous  septum.     Hypoglossal  membrane. 
Arteries. 
Nerves : — 

Mandibular  division  of  the  fifth. 
Glosso-pharyngeal. 
Superior  laryngeal. 
Hypoglossal. 
Chorda  tympani. 
The  lymphatics  of  the  mouth  and  tongue,  691.     (676) 

The  larynx  will  now  be  considered.  With  prepared  specimens  at  hand,  read  the  description  of  the 
cartilages  of  the  larynx,  and  study  their  arrangement  and  relations.  The  cartilages  of  the  specimen 
undergoing  dissection  will  be  gradually  exposed  as  the  dissection  proceeds. 

Larynx,  938.     (917) 
Cartilages :  — 

Single  cartilages. 

Paired  cartilages. 

Hyaline. 

Yellow  elastic. 

Thyroid  cartilage,  939-40.     (918-19) 

Outer  surface. 

Inner  surface. 

Anterior,  or  isthmic  border,  pomum  Adami. 

Superior  border. 

Inferior  border. 

Superior  cornua. 


40  OUTLINES    OF  ANATOMY. 

Thyroid  cartilage: — 
Inferior  cornua. 
Cricoid  cartilage,  940-1.     (919—20) 

Anterior  and  posterior  portion.     Superior  and  inferior  border. 
Posterior  quadrate  portion. 
Anterior  portion. 
Inner  surface. 
Superior  border. 
Inferior  border. 
Arytenoid  cartilages,  941.     (920) 

Three  surfaces.     Three  borders. 
Base.     Apex.     Angles. 
Surfaces:  — 

Posterior.     Anterior.     Internal. 
Base. 
Angles: — 

Anterior.     External,  or  muscular.     Internal. 
Borders:  — 

Internal.     External. 
Apex. 

Cornicula  laryngis,  or  cartilages  of  Santorini,  942.     (921) 
Cuneiform  cartilages,  or  cartilages  of  Wrisberg,  943.     (921) 
Calcification.     Cartilage  triticea. 
Joints  of  the  larynx,  944-5.     (923) 
Crico-thyroid  joints. 
Crico-arytenoid  joints. 

Posterior  crico-arytenoid  ligament. 
Crico-arytenoid  ligament. 
"  Cricoid  articular  surface." 
"The  arytenoid." 
Rotates. 
Glides. 

A  general  examination  should  now  be  made  of  the  specimen  to  be  dissected,  and  the  arrangement  of 
its  parts  studied,  so  far  as  is  possible,  without  dissection.  Fig.  507,  P.  922  (901)  shows  the  parts  dis- 
played by  an  examination  of  the  upper  extremity  of  the  larynx,  also  Figs.  533-4. 

The  epiglottis,  941-2.     (920-1) 
Glosso-epiglottidean  folds. 
Cushion  of  the  epiglottis. 
Aryteno-epiglottidean  folds. 
Pharyngo-epiglottidean  fold. 
The  interior  of  the  larynx,  947-8-9-50.     (926-7-8-9) 

Superior  aperture,  or  opening  of  the  glottis.     Sinus  pyriforrnis. 
Mucous  membrane. 
Suprarimal  portion  : — 
Ventricle. 
Laryngeal  pouch. 

(Compressor  sacculi  laryngis.) 
Superior  or  false  vocal  cords.     Fossa  innominata. 
Rima  glottidis. 
Infrarimal  portion. 

Dissection  of  the  Larynx. 

Sever  the  tongue  from  the  hyoid  bone.  Remove  the  fibres  of  origin  of  the  inferior  constrictor. 
Expose  the  thyro-hyoid  membrane  and  ligaments  and  clean  the  superficial  muscles  of  the  larynx, 
carefully  preserving  the  laryngeal  nerves  and  vessels. 


Thyro-hyoid  membrane.     Thyro-hyoid  ligaments,  943.     (922) 

Demonstrate  the  crico-thyroid   muscles  and  < 
between  the  muscles. 

Crico-thyroid,  945  ;  Fig.  537.     (924) 


Demonstrate  the  crico-thyroid   muscles  and  expose  the  portion  of  the  crico-thyroid  membrane 
between  the  muscles. 


HEAD  AXD  ANTERIOR    CERVICAL   STRUCTURES.  41 

Crico-thyroid  membrane,  943.     (922) 
Crico-arytenoideus  posticus,  945  ;  Fig.  535.     (924) 

Divide  the  thyroid  cartilage  by  a  vertical  incision  just  to  the  right  of  the  anterior  median  line  ; 
carefully  raise  the  right  portion  of  the  cartilage;  divide  the  ligaments  and  remove  it,  exposing  the 
structures  underneath. 

Crico-arytenoideus  lateralis,  945-6  ;  Fig.  528.     (924) 
Thyro-arytenoideus  muscle,  946-7;  Fig.  528.     (524-5) 
Arytenoideus,  947;  Fig.  528.     (925-6) 

Aryteno-epiglottideus  muscle. 
Thyro-epiglottideus,  947;  Fig.  528.     (926) 

Carefully  remove  the  crico-arytenoideus  lateralis  and  the  thyro-arytenoideus,  and  expose  the  outer 
surface  of  the  lateral  portion  of  the  crico-thyroid  membrane  and  thyro-arytenoid  ligaments. 

Crico-thyroid  membrane,  943-4.     (^922-3) 

True  vocal  cords  or  inferior  thyro-arytenoid  ligaments. 
Superior  thyro-arytenoid  ligaments,  944,     (923) 

Divide  the  crico-thyroid  membrane  and  vocal  cords  on  the  right  side  by  a  vertical  incision  in  the 
median  line  of  the  lateral  wall ;  the  interior  of  the  larynx  will  now  be  exposed,  and  the  vocal 
cords,  etc.,  of  the  left  side  should  now  be  studied  from  within.  The  nerves  and  vessels  can  then 
be  followed  on  the  left  side. 

Nerves,  950;  Fig.  535.     (928-9) 

The  superior  laryngeal. 

Inferior  laryngeal : — 
Anterior  branch. 
Posterior  branch. 

Arteries.     Veins.     Lymphatics,  950.     (929) 
Lymphatics  of  the  larynx,  692.     (676) 

Laryngeal  glands. 

Hyo-epiglottidean  ligament.     Periglottis,  942.     (921) 
Epiglottis,  941-2.     (920) 

Internal  Orbital  Region. 

\Vith  the  saw  cut  through  the  frontal  bone  and  the  plate  forming  the  roof  of  the  orbit.  Make  two  in- 
cisions ;  the  outer  one  extending  from  the  outer  end  of  the  sphenoidal  fissure  to  the  outer  angle  of  the 
orbit,  and  the  inner  one  from  a  point  just  external  to  the  optic  foramen  to  the  inner  side  of  the  orbit, 
but  external  to  the  pulley  of  the  superior  oblique  muscle.  Beginning  at  the  posterior  border,  raise  and 
tilt  forward  this  triangular  plate,  exposing  the  orbital  periosteum  underneath. 

Fascia  of  the  orbit,  (T),  (2),  (3),  893.     (873) 

Orbital  periosteum,  or  periorbita,  894.     (874) 

Divide  the  periosteum  in  the  middle  line  of  the  orbit,  and  transversely  at  the  anterior  border  of  the 
orbit.  Reflect  the  fascia  each  way  from  the  median  incision  and  expose  the  structures  within. 

Cavity  of  the  orbit,  general  arrangement  of  its  contents,  890-1.     (870) 
The  frontal  nerve,  796.     (778) 

Trace  the  supraorbital  and  supratrochlear  branches  to  the  point  of  exit  from  the  orbit. 

The  supraorbital  artery,  531.     (522) 

Branches: — Periosteal.     Muscular.     Diploic.     Trochlear.     Palpebral. 
Lachrymal  nerve,  796.     (778) 
Lachrymal  artery,  530—1.     (521-2) 

Recurrent  lachrymal.     Muscular.     Malar  branches.     Palpebral  branches. 
The  lachrymal  gland,  904-5.     (883-4) 

Carefully  raise  the  gland  and  tease  out  the  thread-like  ducts  passing  from  the  gland  to  the  con- 
junctival  sac. 

Nerves  of  the  orbit,  900—1.     (879-80) 
Motor.     Sensory.     Sympathetic. 

A.  Motor  nerves. 

B.  Sensory  nerves. 

C.  Sympathetic  nerves  of  the  orbit. 
Fourth  or  trochlear  nerve,  793-4,  900.     (775-6,  880) 

4 


42  OUTLINES  OF  ANATOMY. 

Muscles  of  the  orbit,  891-2.     (870-1) 

(Superior  and  inferior  recti.     Superior  and  inferior  obliques-.) 
(Internal  and  external  recti.     Levator  palpebrae  superioris.) 

Fascia  of  the  orbital  muscles,  2,  894-5-6.     (875-6) 

The  sheaths  of  the  orbital  muscles  and  the  check  ligaments  will  be  developed  as  the  dissection  \  ro- 
ceeds. 

Levator  palpebrse  superioris,  892.     (872) 

Divide  the  frontal  nerve  and  turn  it  forward,  also  divide  the  levator  palpebns  superioris  midway 
between  the  origin  and  insertion,  reflecting  the  anterior  portion  forward  and  the  posterior  portion  to 
the  origin.  The  eyeball  should  be  distended  ;  to  do  this,  make  a  small  oblique  puncture  at  the  junc- 
tion of  the  sclerotic  and  cornea,  insert  the  tip  of  a  small  blowpipe,  and  innate  the  eyeball.  The  supe- 
rior rectus  should  then  be  exposed. 

The  superior  rectus  (four  recti  muscles),  892.     (871-2) 
The  superior  oblique,  trochlea,  892-3.     (872-3)! 

Divide  the  superior  rectus  in  the  same  manner  as  the  levator  palpebrse  superioris^and  reflect  the  divi- 
sions. Carefully  remove  the  fat  and  fascia  and  expose  the  structures  posterior  to  the  eyeball,  noting 
the  plan  of  formation  of  the  sheaths  of  the  muscles  as  they  are  exposed.  The  optic  nerve  will  be 
exposed,  and,  crossing  the  optic  nerve,  the  nasal  nerve  and  the  ophthalmic  artery  and  vein.  On  the 
outer  side  of  the  optic  nerve,  close  to  the  ophthalmic  artery,  is  the  lenticular  ganglion ;  the  roots  of  the 
ganglion  and  the  branches  from  it  should  be  carefully  traced. 

The  nasal  nerve,  796-7,  901.     (778-9,  880) 

Branches: — Long  root  to  the  lenticular  ganglion. 
Long  ciliary  nerves. 
Infratrochlear  nerve. 

Lenticular,  ciliary,  or  ophthalmic  ganglion,  797,  901.     (779,  881) 
Motor  or  short  root.     Sensory  or  long  root. 
Sympathetic  root.     Short  ciliary  nerves. 
Optic  nerve,  791,  897-8.     (773,  877-8) 

Dural  sheath,  pial  sheath. 

Ophthalmic  artery,  530-1-2-3,  899.     (521-2-3-4,  879) 
Branches  of  the  ophthalmic  artery  :  — 
Arteria  centralis  retinae. 
Muscular  branches. 
Ciliary  arteries: — 
Short  posterior. 
Long  posterior. 
Anterior. 

Posterior  ethmoidal : — 
Ethmoidal  branches. 
Meningeal  branches. 
Nasal  branches. 
Anterior  ethmoidal : — 

Ethmoidal.     Meningeal.     Nasal. 
Frontal.     Cutaneous  or  terminal. 

Palpebral.     Frontal.     Nasal.     Lachrymal.     Transverse  nasa^. 
Veins  of  the  orbit,  663-4-5,  900.     (650-1,  879)  » 
Ophthalmic  vein,  or  common  ophthalmic  vein. 
Superior  ophthalmic  vein. 
Tributaries: — 

Superior  muscular  branches. 
Ciliary  veins :  — 

Anterior  and  posterior  set. 
Anterior  and  posterior  ethmoidal  veins. 
Lachrymal  vein. 
Central  vein  of  the  retina. 
Inferior  ophthalmic  vein. 
Tributaries : — 

Inferior  muscular. 

Lower  posterior  ciliary  veins. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  43 

The  lymphatic  system  of  the  orbit,  901.     (881) 
Third  nerve,  791-2-3,  900.     (774~5>  880) 

Superior  division.     Inferior  division. 
Sixth  nerve,  805-6,  900.     (787-8,  880) 
The  (four)  recti  muscles,  892.     (871-2) 

"Internal  rectus.     Inferior  rectus.     External  rectus." 
Tenon's  capsule.     Tenon's  space,  897.     (876) 
Inferior  oblique,  893.     (872) 

Relation  of  Tenon's  capsule  to  the  oblique  muscles,  897.     (876) 
Action  of  the  ocular  muscles,  893.     (872—3) 
Principal  axes. 

Abduction  and  adduction. 
Rotation  of  the  cornea. 
Action  of: — 

External  rectus.  Internal  rectus. 
Superior  rectus.  Inferior  rectus. 
Superior  oblique.  Inferior  oblique. 

Divide  the  muscles  and  the  optic  nerve,  and  remove  the  eyeball  from  the  optic.  Note  the  form  of  the 
eyeball,  and  expose  the  insertion  of  the  ocular  muscles.  The  orbital  nerve  should  be  traced,  and  the 
periosteum  of  the  lower  portion  of  the  orbit  examined. 

Orbital  or  temporo-malar  nerve,  798—9.     (780—1) 

Temporal  branch.     Malar  branch  (orbital  portion). 
Orbital  periosteum  or  periorbita,  orbital  muscle,  894.     (874) 
Examination  of  the  eyeball,  878-9-80.     (858-9-60) 

Anterior  and  posterior  pole. 

Sagittal  axis. 

Equator. 

Otic  Ganglion.     Maxillary  Division  of  the  Fifth  Nerve,  etc. 

Expose  the  otic  ganglion  ;  to  find  the  ganglion,  follow  the  nerve  to  the  internal  pterygoid,  802.  (783-4) 
— toward  its  origin,  near  its  commencement,  it  gives  off  a  branch  which  can  be  traced  to  the  ganglion. 

Otic  ganglion,  805.     (787) 
Motor  root. 
Sympathetic  root. 
Branches. 

The  trunk  of  the  maxillary  division  of  the  fifth  nerve  should  now  be  exposed.  With  the  saw,  divide 
the  malar  process  of  the  maxilla  by  a  cut  just  external  to  the  infraorbital  groove ;  make  a  second  cut 
from  the  root  of  the  zygoma  inward  and  forward  to  the  middle  of  the  sphenoidal  fissure  and  remove  the 
intermediate  portions  of  bone.  With  the  chisel,  chip  away  the  bone  and  expose  the  nerve  and  its 

branches  in  place. 

Maxillary  division  of  the  fifth  nerve,  797-8.     (780) 
Posterior  superior  dental  nerves,  799.     (781) 
Middle  and  anterior  superior  dental  nerves,  799.     (781) 
Middle  dental  nerve. 
Anterior  dental  nerve  :  — 
Nasal  branch. 

Ganglion  of  Valentin. 
Ganglion  of  Bochdalek. 

Internal  maxillary  artery  : — 

Infraorbital  branch,  526-7.     (517-18) 
Orbital. 

Anterior  dental  branch. 
Nasal  branches. 

With  the  saw  divide  the  anterior  portion  of  the  skull  into  two  lateral  parts  by  a  sagittal  cut  passing 
just  to  one  side  of  the  nasal  septum.  The  septum  must  not  be  injured. 

The  Nasal  Fossae.     Meckel's  Ganglion,  etc. 

The  mucous  membrane,  etc.,  930-1-3.     (909—10—12) 
Vestibule.      Roof.     Floor. 


44  OUTLINES  OF  ANATOMY. 

The  Nasal  Fossae — Mucous  Membrane,  etc.:  — 
Superior  meatus. 
Middle  meatus. 
Inferior  meatus. 

Expose  and  trace  the  nerves  and  vessels ;  first,  those  of  the  septum  ;  then  remove  the  septum  and 
trace  the  nerves  and  vessels  of  the  lateral  walls.  The  cartilage  of  the  septum  should  be  exam- 
ined and  its  connections  noted  before  it  is  removed. 

Septal  cartilage,  928.     (907) 
Anterior  border. 
Posterior  border. 
Inferior. 
The  nerves*  933-4.     (912) 

Olfactory,  or  special  nerves  of  smell : — 

Posterior.     Anterior. 
Nasal  branch  of  the  ophthalmic. 

Vidian,  with  the  upper  anterior  branches  of  Meckel's  ganglion. 
Naso-palatine. 

Anterior  dental  branch  of  the  maxillary  division  of  the  fifth  nerve. 
Anterior,  or  large  palatine  nerve. 
Arteries,  Veins,  934.     (912-13) 
Spheno-palatine :  — 

Internal,  or  naso-palatine  branch  : — 

Supplies — the  septum. 

External  branch  :  — 

Supplies — antrum,   frontal   sinus,    ethmoidal  cells,   turbinated  bones 

meatuses. 
Anterior  and  posterior  ethmoidal  arteries:  — 

Supply — septum,  roof,  outer  wall,  posterior  ethmoidal  cells. 
Descending  palatine: — 

Branches  to — inferior  meatus  and  lower  turbinal  bone. 
Veins :  — 

Spheno-palatine,  ethmoidal,  alveolar. 
Communications. 
Lymphatics.     Lymphatics  from  the  interior  of  the  nose,  691.     (676) 

With  the  chisel  carefully  chip  away  the  inner  wall  of  the  posterior  palatine  canal,  and  expose 
Meckel's  ganglion  and  the  branches  to  and  from  it. 

Spheno-palatine,  nasal,  or  Meckel's  ganglion,  800-1.     (782-3) 
Descending  branches  :  — 

Great,  or  anterior  palatine  : — 
(Inferior  nasal  nerves.) 

Posterior,  or  small  palatine. 

External  palatine  nerve. 
Posterior  branch. 
Pharyngeal  branch. 
(Internal  branches)  :  — 

Superior  nasal. 

Septal  branches: — Naso-palatine  nerve,  or  nerve  of  Cotunnius. 
Ascending,  or  orbital  branches. 

Branches  of  the  third  part  of  the  internal  maxillary  artery,  526-7.     (517-18) 
(Posterior  dental,  or  alveolar)  : — 

Antral.     Dental.     Alveolar,  or  gingival.     Buccal.' 
(Infraorbital)  :  — 

Orbital.     Anterior  dental  branch.     Nasal  branches. 
Posterior,  or  descending  palatine  branch  : — 

Anterior  branch. 

Posterior  branch. 
Vidian  artery  : — 

Pharyngeal.     Eustachjan.     Tympanic. 


HEAD   AND   ANTERIOR   CERVICAL   STRUCTURES.  45 

Pterygo-palatine  artery,  or  pterygo-pharyngeal :  — 

Pharyngeal.     Eustachian.     Sphenoidal. 
Spheno-palatine,  or  naso-palatine  artery  : — 

Pharyngeal  branch.     Sphenoidal  branch.-    Nasal  branches. 

Ascending  septal  branches. 

With  the  chisel  chip  away  the  wall  and  expose  the  lachrymal  sac  and  the  nasal  duct. 
Lachrymal  sac.     Nasal  duct.     Lachrymal  canal,  905-6.     (884-5) 

With  the  chisel,  chip  away  the  anterior  inferior  wall  of  the  carotid  canal,  and  expose  the  intraosseous 
portion  of  the  internal  carotid. 

Intraosseous  portion,  529.     (520) 

Branches  of  the  intraosseous  portion  : — 
Tympanic. 
Vidian  branch. 

Middle  Ear.     Internal  Ear. 

Remove  the  temporal  bone,  with  the  pinna.  Cut  away  the  squamous  portion  above  the  zygoma.  With 
a  chisel,  chip  away  the  roof  and  anterior  wall  of  the  external  auditory  meatus,  exposing  the  canal  and 
the  outer  surface  of  the  membrana  tympani. 

External  Auditory  Meatus,  909-10.     (888-9) 
Cartilaginous  portion. 
Osseous  portion. 
Lining  membrane. 
Arteries. 
Nerves. 

Carefully  chip  away  the  tegmen  tympani  with  a  small,  sharp  chisel,  and  expose  the  tympanic  cavity. 

The  Middle  Ear,  910-916.     (889-894) 

Membrana  tympani.     Rivinian  segment.     Umbo. 

Structure  :  —Fibrous  layer,  external  and  internal  lamellae. 
Cuticular  covering. 
Mucous  lining. 
Tympanic  cavity:  — 

Roof.     Floor.     Outer  wall. 

Chorda  tympani  nen>e,  Iter  chordae  posterius,^Iter  chordae  anterius. 
Inner  wall  : — Fenestra  ovalis,  fenestra  rotunda,  Fallopian  canal. 
Fenestra  ovalis. 
Fenestra  rotunda :  — 

Membrane  of: — Middle  fibrous  layer. 
Mucous  lining. 
Serous  layer. 
Posterior  wall. 
Anterior  wall. 
Eustachian  tube:  — 
Osseous  portion. 
Cartilaginous  portion. 
Mucous  membrane. 

Ossicles  of  the  ear,  73-4-5.     (85-6-7) 
Malleus: — 

Head.  Neck.  Handle,  or  manubrium.  Slender  process.  Short  process. 
Incus : — 

Body.     Short  process.     Long  process.     Orbicular  tubercle. 
Stapes : — 

Head.     Base.     Crura.     Neck. 
Articulation  of  the  ossicles,  913,  etc.     (892,  etc.) 

The  malleus  with  the  incus.     Capsule.     Meniscus. 
Incus  with  the  stapes. 

Elastic  capsular  ligament. 
Stapes  with  the  margin  of  the  fenestra  ovalis. 


46  OUTLINES  OF  ANATOMY. 

Ligaments  of  the  ossicles  :  — 

Superior  ligament  of  the  malleus. 

Anterior  ligament  of  the  malleus. 

External  ligament  of  the  malleus. 

Ligament  of  the  incus. 
Muscles  of  the  tympanum  :  — 

Tensor  tympani;  arises,  inserted. 

Stapedius ;  arises,  inserted. 

Nerves. 
Mucous  membrane  of  the  tympanum  : — 

(a). 

(^)  Obturator  ligament  of  the  stapes. 

(0- 
Vessels  and  nerves  of  the  tympanum. 

Arteries  : — 

Tympanic  branch.     Stylo-mastoid  branch.     Petrosal  branch. 
Veins. 
Nerves : — 

Tympanic  plexus  : — 

Tympanic  branch  of  glosso-pharyngeal. 

Communicating  branch  from  carotid  plexus  of  sympathetic. 

Great  superficial  petrosal. 

Small  superficial  petrosal. 

With  a  fine  saw  divide  the  petrous  portion  of  a  temporal  bone  by  a  coronal  incision  passing  through 
the  external  and  internal  auditory  canals.  Also  divide,  the  petrous  portion  of  a  temporal  bone  by  a  ver- 
tical incision,  from  the  superior  border  downward  through  the  middle  of  the  mastoid  process.  Some 
idea  of  the  internal  ear  can  be  obtained  by  careful  study  of  these  sections.  This  should  be  supple- 
mented by  the  study  of  specially  prepared  specimens,  in  which  the  osseous  labyrinth  has  been  exposed, 
and  by  models  and  diagrams. 

Internal  Ear,  or  Labyrinth,  916-17-18-19-20.     (895-6-7-8-9) 
Osseous  labyrinth  : — 

Vestibule.     Semicircular  canals.     Cochlea. 
Vestibule  :  — 

Outer  wall,  fenestra  ovalis. 

Inner  wall,  fovea  hemispherica,  aqueductus  vestibuli. 

Roof,  fovea  hemielliptica. 

Openings  : — Behind. 

In  front,  apertura  scalae  vestibuli,  by  which  vestibular 
cavity  communicates  with  the  scala  vestibuli  of 
the  cochlea. 

Three  semicircular  Canals,  ampulla. 
Superior  semicircular  canal. 
Posterior  semicircular  canal. 
External  semicircular  canal. 
Cochlea  :  — 

Base  ;  tractus  spiralis  foraminulentus. 
Modiolus,  or  columella  :  — 

Spiral  canal,  lamina  spiralis,  hamulus,  heliocotrema. 
Lamina  spiralis. 

Scala  vestibuli  and  scala  tympani. 
Scala  vestibuli. 
Scala  tympani. 
Central  axis,  or  modiolus  ;  cupula,  infundibulum. 

Central  canal  of  the  modiolus. 
Membranous  labyrinth:  — 

Perilymph.     Canal  of  the  cochlea. 
Within  the  vestibule  : — 
Utricle  and  saccule. 
Utricle. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  47 

Membranous  Labyrinth — Within  the  Vestibule: — 

Saccule.     Canalis  reuniens. 
Within  each  semicircular  canal. 
Structure: — Tunica  propria. 

Fibrous  investment. 
Epithelial  lining. 
Within  the  cochlea:  — 
Membrana  basilaris. 
Membrane  of  Reissner. 

Ductus  cochlearis,  or  membranous  canal  of  the  cochlea. 

Canalis  reuniens. 
Auditory  nerve  : — 

Superior  division  :  — 

To  utricle,  superior  and  external  semicircular  canals. 
Inferior  division  : — 

To  cochlea,  saccule,  posterior  semicircular  canal. 
Vessels :  — 

Artery  : — Internal  auditory  branch  : — 

To  vestibule  and  cochlea,  with  their  membranous  con- 
tents. 
Veins. 
With  a  small  chisel  chip  away  the  bone  and  expose  the  canal  for  the  facial  nerve. 

Facial  nerve,  807-8.     (788—9) 

"At  its  superficial  origin."     Geniculate  ganglion. 
Branches,  (i)  : — 

Great  superficial  petrosal  nerve. 

Lesser  superficial  nerve. 

External  superficial  petrosal. 

Nerve  to  the  stapedius. 

Chordi  tympani. 

Communicating  twig  to  the  pneumogastric. 

Dissection  of  the  Eyeball. 

For  the  dissection  of  the  eyeball,  procure  several  eyes  of  the  pig,  sheep,  or  ox.  The  eye  of  the  pig  most 
closely  resembles  the  human  eye  in  form  and  structure,  but  on  account  of  its  size  the  eye  of  the  ox  is 
more  readily  dissected.  The  conjunctiva,  ocular  muscles,  and  fat  should  be  carefully  removed,  exposing 
the  eyeball ;  in  removing  these,  note  the  vena  vorticosae  issuing  from  the  sclerotic,  a  little  posterior  to 
the  equator  of  the  eyeball ;  and  near  the  optic  nerve,  the  ciliary  vessels  and  nerves  entering  the  eyeball 
through  the  sclerotic. 

To  obtain  a  general  idea  of  the  arrangement  of  the  parts  composing  the  eyeball  and  for  reference 
during  the  dissection,  make  a  series  of  sections  of  the  eyeball ;  to  do  this  put  a  couple  of  eyes  in  small 
tin  boxes  and  place  in  a  mixture  of  salt  and  crushed  ice  for  three  or  four  hours  till  frozen  solid.  With 
a  fine  saw  divide  one  of  the  eyes  into  an  anterior  and  a  posterior  section,  cutting  it  at  the  equator  of  the 
eyeball ;  divide  the  other  eye  into  two  lateral  halves  by  an  antero- posterior  section,  cut  one  of  these 
halves  into  a  number  of  thin  sections.  Pin  the  sections  in  a  tray  and  cover  with  water ;  they  can  then 
be  examined  to  advantage  with  a  glass. 

General  structure  of  the  eyeball. 

On  examination  of  the  sections  it  will  be  seen  that  the  eyeball  consists  of  tunics  and 
of  refracting  media  or  humors  : — 

The  tunics  forming  the  coats  of  the  eyeball  are  : — 

1.  Tlie  sclerotic  and  cornea. 

2.  The  choroidy  ciliary  processes  and  iris, 
j.   The  retina. 

The  refracting  media  or  humors  are  : — 
/.    The  vitreous  humor. 
2.   The  crystalline  lens  and  capsule, 
j.   The  aqueous  humor. 

Divide  an  eye  at  the  equator  of  the  eyeball  and  note  the  parts  seen  in  each  hemisphere. 

i.  Posterior  hemisphere,  880.     (860) 

Retina.     Retinal  pigment  layer.     Membrana  suprachoroidea. 


48  OUTLINES  OF  ANATOMY. 

2.   Anterior  hemisphere,  880— i.     (860— i) 

Crystalline  lens.     Ora  serrata.     Iris.     Lens  capsule. 
Suspensory  ligament.     Ciliary  muscle. 

The  coats  of  the  eye  should  now  be  systematically  demonstrated  on  a  fresh  eye. 

The  outer,  fibrous  coat  of  the  eye,  881.     (861) 

Lamina  cribrosa,  limbus.     Lamina  cribrosa,  898-9.     (878-9) 

With  a  sharp  knife  carefully  cut  through  the  sclerotic  at  the  equator  of  the  eyeball,  to  the  choroid  ;  with 
a  pair  of  sharp  scissors  continue  the  incision  around  the  eyeball.  Make  three  or  four  incisions  back- 
ward nearly  to  the  optic  nerve  and  carefully  reflect  the  sclerotic  from  the  choroid.  Divide  the  optic 
nerve  close  to  the  inner  side  of  the  sclerotic.  In  the  same  manner  carry  the  dissection  forward  to  the 
margin  of  the  cornea,  carefully  detaching  the  ciliary  muscle  from  the  inner  surface  of  the  sclerotic. 

The  cornea,   881-2.     (861-2) 

Middle  or  vascular  coat  of  the  eye,  uveal  tract,  882-3-4.     (862-3-4) 
The  choroid  :  — 

Membrana  suprachoroidea. 
Membrane  of  Bruch. 
Choroido-capillaris,  Fig.  478. 
Ciliary  body : — 
Corona  ciliaris. 
Orbiculus  ciliaris. 

With  a  small  brush  wash  away  the  pigment  on  one  of  the  anterior  hemispheres,  exposing 
the  ciliary  processes. 

Ciliary  muscle. 

The  arrangement  of  the  fibres  of  the  ciliary  muscle  can  be  studied  to  advantage  only  with  properly 
prepared  and  mounted  sections  and  a  microscope. 

.     The  iris,  sphincter  iridis,  883-4.     (862-3-4) 

Take  an  eyeball  from  which  the  sclerotic  has  been  removed  and  placing  it  in  water,  with  a  fine  brush 
carefully  wash  away  the  pigment  of  the  choroid  and  expose  the  vessels  and  nerves  on  the  surface. 

Ciliary  nerves  of  the  eyeball,  886-7  J  Fig.  479-     (867) 

The  ciliary  system  of  blood-vessels,  888-9  >  Fig8-  479  and  478.     (868-9) 

(1)  Short  posterior  ciliary  arteries. 

(2)  Long  posterior  ciliary  arteries. 

(3)  Anterior  ciliary  arteries. 
Veins: — Vena  vorticosae. 

Anterior  ciliary  veins. 

With  the  eyeball  under  water  carefully  remove  the  choroid,  ciliary  processes,  and  iris  and  expose  the 
outer  surface  of  the  retina. 

The  innermost  or  nervous  coat,  884-5.     (864) 
Pars  ciliaris  retinae. 
The  retina  proper. 

Arteria  centralis  retinae,  887-8.     (867-8) 
Vena  centralis  retinae,  Fig.  478. 
Aqueous  humor,  886.     (867) 

Anterior.     Posterior  aqueous  chamber. 
Vitreous  humor,  886.     (866-7) 

Suspensory  ligament  of  the  lens,  canal  of  Petit,  886.     (866) 
The  lens,  885-6.     (864-5) 

Equator.     Pole.     Stellate  figures. 
Nucleus.     Cortex. 

Lymphatic  system  of  the  eyeball,  889-90.     (869-70) 
Anteriorly : — 

In  the  cornea. 
In  the  iris. 
Posteriorly. 


HEAD   AND   ANTERIOR   CERVICAL   STRUCTURES.  49 

Dissection  of  the  Brain. 

Before  beginning  the  dissection  of  the  brain,  the  student  should  read  the  chapter  on  the 

mode  of  development — "Neurology,"  708-9-10.     (692-3-4) 

THE  BRAIN. 

The  Arachnoid  and  Pia  Mater  will  now  be  considered. 

The  arachnoid,  715-16.     (699-700) 
Pacchionian  glands. 

Structure  of  a  Pacchionian  body,  718.     (702)  . 

Subarachnoid  tissue,  716-17.     (700-1) 
Subarachnoid  spaces  :  — 

Cisterna  magna. 

Cisterna  pontis. 
Pia  Mater,  717.     (701) 
Lymphatics  of  the  Brain  and  Spinal  Cord,  717-18.     (701-2) 

Subarachnoid  space. 
Cerebro-spinal  fluid. 

Carefully  remove  the  membranes  from  the  surface  of  the  brain.  Beginning  at  the  base,  the  arteries 
should  be  carefully  exposed  and  traced  as  far  as  possible  without  injury  to  the  brain  substance.  The 
main  trunks  can  be  followed,  the  terminal  distribution  of  the  branches  will  be  somewhat  developed 
during  the  process  of  the  dissection.  The  description  of  the  branches  should  be  read  at  this  time  and 
can  be  reviewed  later  as  the  vessels  are  exposed. 

Encephalon  or  brain,  718.     (702) 
Cerebrum.     Mesencephalon. 
Cerebellum.     Peduncles  or  crura. 

Gray  matter.     White  matter. 

Internal  carotid. 

Intercranial  portion,  529.     (520) 

Anterior  cerebral.     Anterior  communicating  artery,  534.     (524-5) 
Branches  of  the  anterior  cerebral  : — 
Communicating : — 

Anterior  communicating. 
Antero  median  branches. 
Ganglionic,  or  central  : — 
Antero-median  group. 
Commissural. 

The  hemispherical,  or  cortical  branches: — 
Orbital. 

Margino-frontal. 
Calloso-marginal. 
Quadrate. 

Middle  cerebral  artery,  534-5.     (525) 
Branches  of  the  middle  cerebral : — 
Ganglionic,  or  central : — 
Caudate. 
Antero-lateral. 
Lenticulo-striate. 

Hemispherical,  or  cortical  branches  : — 
Inferior,  or  orbito-frontal. 
Ascending  frontal. 
Parietal.    • 
Parieto-temporal. 

Posterior  communicating  artery,  533.     (524) 
Branches : — Uncinate. 

Middle  thalmic. 
Anterior  choroid,  533-4.     (524) 


So  OUTLINES  OF  ANATOMY. 

Vertebral  artery. 

Fourth,  or  intercranial  portion,  541.     (532) 
Branches:— 542-3.     (533) 
Posterior  spinal  artery. 
Anterior  spinal  artery. 
Posterior  inferior  cerebellar  :  — 

Internal,  or  inferior  vermiform  branch. 
External,  or  hemispherical  branch. 
The  basilar  artery,^ 5 43-4.     (533-4) 

Branches: — Transverse,  or  pontal  arteries. 
Internal  auditory  artery. 
Anterior  cerebellar. 
Superior  cerebellar. 

Internal,  or  superior  vermiform  branch. 
External,  or  hemispherical  branch. 
Posterior  cerebral  arteries:  — 

Ganglionic,  or  central  branches  : — 
Postero-median  branches. 
Posterior  choroid  branch. 
Postero-lateral  branches. 
Cortical,  or  hemispherical  branches: — 
Uncinate. 
Temporal. 
Temporo-occipital . 
The  circle  of  Willis,  535-6.     (526) 
Formed  : — In  front. 
Laterally. 
Behind. 
Read  : — Summary  of  the  distribution  of  the  cerebral  arteries,  544-5.     (535) 

A.  The  central  branches  : — 

The  two  median  :  — 

Antero-median. 

Postero-median. 

The  four  lateral :  — 

Antero-lateral. 

Postero-lateral. 

B.  The  cortical  branches  : — 

The  anterior  cerebral. 
The  middle  cerebral. 
The  posterior  cerebral. 
The  Cerebral  Veins,  661-2.     (648-9) 
Cortical,  or  hemispherical. 
Central,  or  ganglionic. 

Cortical,  hemispherical,  or  superficial  veins  : — 
Superior  cortical  veins. 
Inferior  cortical  veins. 

Central,  ganglionic,  or  deep  cerebral  veins  :  — 
Vena  magna  Galeni : — 

Tributaries  of  the  veins  of  Galen  : — 
Choroid  vein. 
Vena  corporis  striati : — 

Tributaries. 
Basilar  vein  : — 
Tributaries. 
The  Cerebellar  Veins,  662-3.     (649) 

Superior  and  inferior. 
Superior. 
Inferior. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  51 

The  Veins  of  the  Medulla  and  Pons,  663.     (649) 

Medulla  oblongata. 

Pons. 

The  vessels  and  the  remaining  portion  of  the  membranes  should  now  be  removed  from  the  base  of  the 
brain.  The  superficial  structures  of  the  base  and  the  superficial  origin  of  each  of  the  cranial  nerves 
should  then  be  noted. 

Base  of  the  Brain  : — Dissection,  719-20.     (703-4) 
The  cerebral  hemispheres,  720-1.     (704-5) 
Anterior  pole,  posterior. 
Fissures,  or  sulci. 
Convolutions,  or  gyri. 
Super-external  surface. 
Internal  surface. 
Inferior,  surface. 
Fissures,  721-2-3.     (705-6-7) 

(a)  Great  longitudinal  fissure.     Great  transverse  fissure. 
(£)  Complete  and  incomplete. 
Interlobar  fissures  : — 

Parieto-occipital  fissure  : — 

Internal  parietooccipital  or  internal  perpendicular  fissure. 
External  parieto-occipital  fissure. 
Fissure  of  Sylvius  : — 

Posterior  limb. 

Ascending  limb. 

Anterior  limb. 

Fissure  of  Rolando,  or  central  sulcus. 

Superior  genu.     Inferior  genu. 

Lobes  of  the   Cerebral  Hemispheres  with  Fissures  and  Convolutions,  723-4. 
(707-8) 

Frontal.      Parietal.       Occipital.      Temporo-sphenoidal.     Central   lobe   or 
Island  of  Reil. — Falciform  lobe.     Olfactory  lobe,  rhinencephalon. 

Frontal  lobe,  724-5.     (708—9) 

Surfaces  : — Super-external  or  frontal. 
Inferior,  or  orbital. 
Internal,  or  mesial. 
Frontal  surface,  orbital  margin. 
Praecentral  sulcus. 

Superior  frontal  fissure.     Sulcus  fronto-marginalis. 
Inferior  frontal  fissure. 
Ascending  frontal  convolution. 
Superior  frontal  convolution. 
Middle  frontal  convolution. 
Inferior  frontal  convolution  : — 
Pars  orbitalis. 
Pars  triangularis. 
Pars  basilaris. 
'     Orbital  surface  : — 
Tridate  fissure. 
Olfactory  or  straight  sulci. 
Orbital  convolutions: — 

Internal.     Anterior.     Posterior. 
Straight  convolution,  or  gyrus  rectus. 
Parietal  lobe,  sulcus  subparietalis,  725-6.     (709—10) 
Intraparietal  fissure.     Ramus  occipitalis. 
Ascending  parietal  convolution. 
Superior  parietal  lobe. 
Supramarginal  convolution. 
Angular  gyrus. 


52  OUTLINES  OF  ANATOMY. 

Occipital  lobe,  726-7-8.     (710-11-12) 

Prseoccipital  notch. 

Superior  occipital  fissure.     Ramus  occipitalis. 
Transverse  occipital  fissure. 

Middle  occipital  fissure. 

Inferior  occipital  fissure. 

Superior  occipital  convolution. 

Middle  occipital  convolution. 

Inferior  occipital  convolution. 

Annectant  gyri.     Sulcus  occipitalis  anterior. 
Temporal  lobe,  728-29.     (712-13) 

Parallel  fissure. 

Middle  temporal  fissure. 

Inferior  temporal  fissure. 

Superior  temporal  or  inframarginal  convolution. 

Middle  temporal  convolution. 

Inferior  temporal  convolution. 

Transverse  temporal  convolutions. 
Dissection. 

Central  lobe,  or  island  of  Reil.     Fossa  Sylvii.     Limen  insulae,  729.     (713) 

Sulcus  circularis  Reilii.     Gyri  operti.     Sulcus  centralis  insulse. 
Mesial  and  tentorial  surfaces  of  the  hemisphere,  730-1-2-3.     (713-14-15-16-17) 
Mesial  surface.     Internal  occipital  border. 
Tentorial  surface. 
Calloso-marginal  fissure. 

Sulcus  paracentralis. 

Sulcus  subparietalis. 
Parieto-occipital  fissure. 
Calcarine  fissure. 
Callosal  fissure. 

Dentate  or  hippocampal  fissure. 
Collateral  fissure. 
Marginal  convolution. 
Paracentral  lobe. 

Gyrus  fornicatus,  or  gyrus  cinguli.     Isthmus. 
Praecunius,  or  quadrate  lobe. 
Cuneus,  or  cuneate  lobe. 

Superior  and  inferior  occipito-temporal  convolutions. 
Uncinate  convolution.     Uncus.     Incisura  temporalis.     Tentorial  groove. 

Substantia  reticularis  alba. 
Lobus  lingulis. 

Inferior  occipito-temporal  convolution. 
Impressio  petrosa. 
Falciform  lobe ;  limbic  lobe. 

Outer  segment.     Inner  segment. 
Olfactory  tract,  olfactory  bulb,  788-9.     (770-1) 

Cortex  of  the  tract. 

External  root.     Middle  root.     Internal  root. 
Corpus  callosum,  733-4-5.     (717-18-19) 
Posterior  extremity,  or  splenium. 
Anterior  extremity,  or  genu. 
The  rostrum.     Basal  white  commissure. 
Body. 

By  successive  slices  remove  the  upper  portion  of  the  cerebral  hemispheres  clown  to  the  level  of  the 
corpus  callosum,  exposing  its  upper  surface. 

Striae  longitudinales. 

Raphe. 

Tasniae  tectse. 


HEAD  AND  ANTERIOR   CERVICAL   STRUCTURES.  53 

Fibres  of  the  corpus  callosum  :  — 

Fibres  from  the  genu.     Forceps  minor. 
Fibres  from  the  body : — 
Uppermost  fibres. 
Intermediate  fibres. 
Lowest  fibres. 

Anterior  set. 
Posterior  set.     Tapetum. 
Fibres  from  the  splenium.     Forceps  major. 
Expose  the  lateral  ventricles,  see  Dissection,  735.     (7>9) 

The  Lateral  Ventricles,  735-6-7-8-9.     (719-20-1-2) 
The  body. 
Anterior  cornu. 
Posterior  cornu.     Hippocampus  minor,  or  calcar  avis.     Bulb  of  the  cornu. 

Dissection. 

Inferior  or  descending  cornu. 

Floor.     Roof. 

Eminentia  collateralis. 

Hippocampus  major,  or  cornu  Ammonis. 

Corpus  fimbriatum,  taenia  hippocampi,  or  fimbria. 
Choroid  plexuses. 

Foramina  of  Monro.     Foramen  commune  anterius. 
Fascia  dentata,  or  dentate  convolution. 
Fascia  cinearea. 

Dissection. 

Basal  ganglia  of  the  Hemispheres,  739-40-1-2.     ( 7 •* 2-3-4-5) 
Nucleus  caudatus  : — 

Head.     Tail. 
Nucleus  lenticularis. 

Internal  and  external  medullary  laminae. 
Globus  pallidus. 
Putamen.     Ansa  lenticularis. 
Claustrum. 
Amygdaloid  nucleus. 

Taenia  semicircularis,  or  stria  terminalis.     Lamina  cornea. 
Inner  capsule,  genu. 
Outer  capsule. 
Anterior  commissure. 

Dissection. 

Fornix,  742-3.     (725-6) 

Body.     Posterior  pillars.     Lyre.     Fimbria. 

Anterior  pillars. 
Corpora  albicantia.     Bundles  of  Vicq  d'Azyr. 

Septum  lucidum,  743.     (726) 

Fifth  or  Sylvian  ventricle,  743.     (726) 

Great  transverse  fissure  of  the  cerebrum,  743.     (726-7) 

Velum  interpositum,  or  tela  choroidea  superior,  743-4.      727-8. 
Choroid  plexuses,  744.     (728) 
Dissection,  744-5.     (728) 

The  Thalamencephalon,  745-6-7-8-9.     (728-9-30-1-2-3) 
Third  ventricle. 

Posterior  commissure. 

Middle  or  gray  commissure. 

Floor. 

Central  gray  matter  of  the  third  ventricle. 


54  OUTLINES  OF  ANATOMY. 

Optic  thalami. 

Anterior  tubercle. 

Posterior  tubercle,  or  pulvinar. 

Superior  surface. 

Sulcus  choroideus. 

Stria  pinealis,  or  peduncle  of  the  pineal  body. 
Trigonum  habenulae. 
Internal  surface. 

Middle  or  gray  commissure. 
External  surface. 
Inferior  surface. 

Antero-superior,  external  and  internal  nuclei. 
Ansa  lenticularis. 

The  pineal  body. 
Stalk. 
Peduncle  or  stria  pinealis. 

Recussus  pinealis. 

Posterior  commissure. 

Basal  gray  commissure. 

Posterior  perforated  space.     Foramen  caecum  anterius. 

Corpora  albicantia.     Bundle  Vicq  d'Azyr. 

Tuber  cinereum.     Infundibulum.     Recessus  infundibuli. 

Pituitary  body,  or  hypophysis  cerebri. 

Anterior  lobe.     Posterior  lobe. 
Pituitary  gland.     Pituita. 

Optic  commissure. 
Lamina  cinearea. 

Dissection. 

The  Mesencephalon,  749-50-1-2-3.     (733-4-5-6) 

Aqueduct  of  Sylvius,  or  iter  e  tertio  ad  quartus  ventriculorum. 
Lamina  quadrigemina.     Corpora  quadrigemina. 

Gray  matter  of  the  aqueduct. 

Nucleus  of  the  third  and  fourth  nerves. 

Nucleus  of  the  descending  root  of  the  fifth  nerve. 

Corpora  quadrigemina. 

Nates.     Testes.     Frenulum  veli. 
Nates.     Brachia  of  the  nates. 

Testes.     Brachia  of  the  testes,  or  inferior  brachia. 
Corpus  geniculatum  internum. 
Corpus  geniculatum  externum. 
Crura  cerebri : — 

(1)  Tegmen. 

(2)  Substantia  nigra. 

(3)  Crusta. 

Oculo-motor  and  lateral  grooves.     Fillet. 
The  crusta,  or  pes. 

Dissection. 

Crusta : — Central  third. 
Outer  third. 
Inner  third. 

Tegmental  portions.     Subthalamic  body. 
Tegmental  or  red  nucleus. 
Superior  cerebellar  peduncle. 
Fillet. 
Posterior  longitudinal  bundle. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  55 

The  Epencephalon,  753-760.     (736~743) 
Dissection. 

Cerebellum  : — 

Superior  vermiform  process.     Valeculecula.     Incisura  marsupialis. 
Folia.     Fissures. 
Peduncles  :  — 
Superior. 
Middle. 
Inferior. 

Great  horizontal  fissure. 
Superior  surface  of  the  cerebellum. 
Superior  vermiform  process. 
Sulcus  cerebelli  superior. 
Quadrate  lobe. 

Anterior  crescentic. 
Posterior  crescentic  portion. 
Posterior  superior  lobe. 
Superior  vermiform  process  : — 

Lobus  centralis.     Alae.     Lingula. 
Monticulus  cerebelli : — 
Culmen. 
Declive. 

Folium  cacuminis. 
Inferior  surface  of  the  cerebellum. 
Lobes: — Posterior  inferior. 
Slender. 
Biventral. 
Tonsillar  lobe. 
Flocculus. 

Inferior  vermiform  process  : — 
Tuber  valvulae. 
Pyramid. 

Uvula.     Furrowed  band. 
Nodule,  or  laminated  tubercle.     Inferior  medullary  velum. 

Dissection. 

White  matter  of  the  cerebellum. 
Arbor  vitae : — 

Vertical  branch. 
Horizontal  branch. 

Gray  matter  in  the  interior  of  the  cerebellum. 
Nucleus  emboliformis. 
Nucleus  globosus. 
Nucleus  fastigii. 
Fourth  ventricle. 

Roof: — Valve  of  Vieussens,  or  superior  medullary  velum. 
Inferior  medullary  vela,  commissurae  ad  flocculos. 
Choroid  plexuses. 
Tela  choroidea  inferior. 
Obex. 
Ligulae. 
Floor  of  the  fourth  ventricle. 

Sulcus  longitudinalis  medianus.     Ventricle  of  Arantius. 
Striae  medullares  or  striae  acusticae. 
Posterior  moiety  of  the  floor. 

Fovea  inferior  or  posterior.     Ala  cinerea,  trigonum  vagi. 
Trigonum  hypoglossi. 
Tuberculum  acusticum. 


5 6  OUTLINES   OF  ANATOMY. 

Floor  of  the  Fourth  Ventricle:  — 

Anterior  moiety  of  the  floor. 

Eminentia  teres.     Fasiculus  teres. 
Fovea  superior.     Conductor  sonorus. 
Locus  cseruleus.     Substantia  ferruginea. 
Pons  varolii. 

Dorsal  surface. 

Ventral  surface. 

Superior  border. 

Inferior  border.     Oblique  fasciculus. 

Ventral  region. 

Transverse  fibres:  — 

(a)  Commissural. 

(b)  Decussating  fibres. 

(c)  Fibres. 
Longitudinal  fibres. 

Upper  or  legmen tal  region. 
The  Metencephalon,  760-766.     (743-749) 
Medulla  oblongata,  or  bulb. 
Anterior  surface. 

Posterior  surface.     Ventricular  part. 
Fissures : — Anterior  fissure. 

Foramen  caecum  posterius,  or  foramen  caecum  of  Vicq  d' Azyr. 
Sulcus  lateralis  ventralis.     Postolivary  sulcus. 
Posterior  surface. 

Posterior  fissure. 
Sulcus  paramedianus  dorsalis. 
Sulcus  lateralis  dorsalis. 
Anterior  area. 

Pyramidal  bodies. 
Funiculus  anterior. 
Lateral  area.     Lateral  column. 
Gray  tubercle  of  Rolando. 
Olivary  body.     External  arciform  fibres. 
Posterior  area  of  the  medulla. 
Funiculus  gracilis.     Clava. 
Funiculus  cuneatus.     Cuneate  tubercle. 
Restiform  body. 
Dissection. 
Internal  structure  of  the  medulla. 

Arrangement  of  the  gray  matter. 
Olivary  nucleus. 

Nucleus  of  the  clava  and  the  nucleus  cuneatus. 
Cranio-cerebral  Topography,  766  to  771.  (749  to  754) 
Guide  points: — 

Glabella.     Naso-frontal  groove.     Orbital  arch.     External  angular  process. 
Zygoma. 

External  auditory  meatus.     Mastoid  process.     Superior  nuchal  line. 
External  occipital  protuberance,  or  inion. 
Parietal  eminence.     Sutures.     Lambda. 

Relation  of  the  margin  of  the  hemisphere  to  the  cranial  wall. 
Orbital  margin  of  the  hemisphere.     Sylvian  point. 
Position  of  the  principal  fissures : — 
Fissure  of  Rolando. 
Naso-lambdoidal  line. 
Fissure  of  Sylvius. 
External  parieto-occipital  fissure. 
Angular  gyrus. 
Supramarginal  convolution. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  57 

The  Peripheral  Nervous  System,  786.     (768—9) 

In  the  brain  laboratory,  with  the  base  of  a  brain,  models,  diagrams,  and  prepared  sec- 
tions at  hand,  the  student  should  study  the  general  description  of  each  cranial  nerve  ; 
the  branches  and  distribution  will  be  demonstrated  on  the  subject  as  the  dissection  pro- 
ceeds.. 

First  or  olfactory  nerves,  788-9.     (770-1-2) 
Olfactory  tract.     Olfactory  bulb. 
Cortex  of  the  tract. 
External  root,  middle,  internal  root. 
Optic  nerves,  790-1.     (772-3) 

Optic  chiasma,  or  commissure. 

Constitution  of  the  optic  chiasma. 
Uncrossed  fibres. 
Crossed  fibres. 
Commissural  fibres. 
Optic  tract. 

Internal  root. 
External  root. 

Optic  radiation.     Gudden's  Commissure.     Meynert's  Commissure. 
Third  or  oculo-motor  nerve,  791—2.     (774— 5) 
Fourth  or  trochlear  nerve,  793.     (775-6) 
Fifth  or  trigeminal  nerve,  794-5.     (776-7) 
Portio  major,  ascending  root. 
Portio  minor,  nucleus,  descending  root. 
Ascending  root : — 

Accessory  sensory  nucleus. 

Cerebellar  root. 

Descending  root :  — 

Motor  nucleus. 

Gasserian  ganglion. 

Sixth  or  abducent  nerve,  805-6.     (787-8) 
Seventh  or  facial  nerve,  806.     (788-9) 
Genu  nervi  facialis. 
Pars  intermedia  of  Wrisberg. 
Geniculate  ganglion. 
Auditory  nerve,  811-12-13.     (792-3-4) 
Lateral  root. 
Mesial  root. 

Small-celled  or  chief  nucleus. 
Large-celled  or  Deiter's  nucleus. 
Accessory  nucleus. 

Tuberculum  acusticum.     Nucleus  funiculi  teretis.     Superior  olive. 
Lateral  root : — 

Conductor  sonorus. 
Mesial  root. 

Glosso-pharyngeal  nerve,  813.     (794-5) 
Small-celled  nucleus. 
Large-celled  nucleus. 
Ascending  root. 
Jugular  ganglion. 
Petrous  ganglion. 

Pneumogastric,  or  vagus  nerve,  815-16-17.     (796-7) 
Spinal  accessory  nerve,  819—20.     (800-1) 
Hypoglossal  nerve,  820-1.     (801-2) 

Landmarks  of  the  Back,  1170-1180.     (1146-1156) 
Median  furrow. 
Vertebral  spines. 
Thoracic  spines. 
5 


58  OUTLINES  OF  ANATOMY. 

Landmarks  of  the  Back  :  — 

Lumbar  spines. 

Muscles. 

Trapezius. 

Latissimus  dorsi. 

Triangle  of  Pettit. 

Origin  of  spinal  nerves. 

Scapula,  its  muscles  and  arterial  anastomoses. 

Lumbar  fascia. 

Viscera,  see  table  indicating  the  position  of  organs  in  cervical,  thoracic,  lumbar,  and 

sacral  regions. 

Dissection  of  the  Posterior  Cervical  Structures  and  the  Back. 

The  dissector  of  the  Uppet  Extremity  should  participate  in  the  dissection  of  the  back, 
until  the  dissection  of  the  serratus  magnus  is  completed. 

Make  a  median  incision  from  the  occipital  protuberance  to  the  sacrum.  Make  a  transverse  incision 
from  the  spine  of  the  seventh  cervical  vertebra  to  the  end  of  the  acromion  process,  also  from  the  spine 
of  the  last  dorsal  vertebra  upward  and  outward  to  the  same  point.  Make  an  incision  from  the  spine 
of  the  last  lumbar  vertebra  to  the  crest  of  the  ilium  and  along  the.  crest.  Turn  the  skin  outward  from 
the  median  line.  The  dissectors  of  the  lower  extremity  will  at  the  same  time  expose  the  sacral,  coccy- 
geal,  and  gluteal  regions.  The  superficial  lumbar,  sacral,  and  coccygeal  nerves  should  be  noted  by 
the  dissectors  of  the  back,  also. 

Superficial  fascia,  302.     (305) 
Superficial  nerves,  Fig.  452;  P.  826.     (P.  807) 
Cervical  nerves,  825.     (806) 

Internal  branches,  3d,  4th,  5th. 
Thoracic  nerves,  827.     (808) 

Internal  branches — from  upper  six  or  seven  nerves. 
External  branches — from  lower  five  or  six  nerves. 
Lumbar  nerves,  827-8.     (808) 

External  branches  of  upper  three  nerves. 
Sacral  and  coccygeal  nerves,  828.     (808-9) 

External  branches  of  the  upper  three  nerves.     (See  internal  branches.) 
Lower  two  sacral  and  the  coccygeal  nerve. 

The  superficial  arteries  are  derived  from  branches  of  the  intercostal  and  lumbar 
arteries  and  accompany  the  superficial  nerves:  — 
From  intercostal  arteries  : — 

Dorsal  branch,  582;  Fig.  362.     (571-2) 

(ii)  Muscular  branch. 
From  lumbar  arteries: — 

Dorsal  branch,  588.     (577) 

Turn  off  the  superficial  fascia  and  expose  the  deep  fascia. 

The  deep  fascia,  302.     (305) 

Reflect  the  deep  fascia  from  the  surface  of  the  trapezius  and  latissimus  dorsi. 

Trapezius,  302-4;  Fig.  262.     (305-7) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  trapezius  near  its  origin  and  turn  outward  to  the  insertion.  Note  the  spinal  accessory  nerve 
and  the  branches  from  the  cervical  plexus  entering  the  deep  surface  of  the  muscle. 

Spinal  accessory  nerve,  819-20.     (800-1) 
Branches  to  the  trapezius,  831.     (812) 

Subtrapezial  plexus. 
Latissimus  dorsi,  307-8;  Figs.  262  and  269.     (310) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.     Relations.    Variations. 

Divide  the  latissimus  dorsi  transversely  on  a  line  with  the  vertebral  border  of  the  scapula,  reflect  the 
inner  portion  to  the  origin,  note  the  relations,  then  remove  the  inner  portion  of  the  muscle.  In  the 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES.  59 

neck,  trace  the  superficial  cervical  artery,  expose  the  origin  of  the  omo-hyoid — 476 — and  follow  the 
supra-scapular  artery — 546  (536) — and  nerve — 834  (815) — to  the  point  where  they  enter  the  supra- 
spinous  fossa. 

Superficial  cervical  artery,  548      (538) 

Levator  anguli  scapulae,  305  ;  Figs.  263  and  266.     (307-8-9) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 
The  rhomboidei,  305-6-7  ;  Fig.  263.     (309-10) 
Rhomboideus  minor: — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Rhomboideus  major: — 

Origin.     Insertion.     Structure.     Nerve-supply.     Variations. 
Action.     Relations  of  the  two  rhomboidei. 

Divide  the  rhomboids  at  their  origin  and  turn  outward  to  the  insertion.  Note  the  nerve  to  the  rhom- 
boids and  follow  the  posterior  scapular  artery  along  the  border  of  the  scapula. 

Nerve  to  the  rhomboids,  834.     (815) 
Posterior  scapular  artery,  547.     (538) 

Expose  the  outer  surface  of  the  serratus  magnus,  then  draw  the  scapula  forward  and  outward  and  ex- 
pose the  inner  surface.  Demonstrate  the  origin  and  the  insertion. 

Serratus  magnus,  313-14-15,  Fig.  267.     (316—17) 
Origin ;  First  part,  Second  part,  Third  part. 
Insertion  ;  First  part,  Second  part,  Third  part. 
Structure.     Xerve-supply.     Action.     Relations.     Variations. 

Divide  the  trunks  of  the  brachial  plexus  and  tie  them  to  a  small  splinter  to  preserve  their  relative  posi- 
tion. Cut  the  axillary  artery  at  its  commencement.  Divide  the  muscles  connecting  the  extremity  with 
the  trunk  and  remove  it.  The  remaining  structures  of  the  back  will  now  be  exposed. 

Serratus  posticus  superior,  436-7-8  ;  Fig.  305.     (432) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.     Relations.  Variations. 
Serratus  posticus  inferior,  438;  Fig.  305.     (434) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Divide  the  serratus  posticus  superior  at  its  origin,  and  turn  it  outward  to  the  insertion. 

Splenius:  splenius  capitis,  splenius  colli,  439-40;  305.     (435) 
Splenius  Capitis  :  — 

Origin.     Insertion.     Structure.     Nerve-supply.     Action. 
Splenius  Colli : — 

Origin.     Insertion.     Structure.     Nerve-supply.     Action. 

Relations  of  the  splenius.     Variations. 

Divide  the  splenius  at  its  origin  and  throw  it  upward  to  the  insertion. 

The  vertebral  aponeurosis,  438  ;  Fig.  305.     (434) 
Posterior  aponeurosis  or  lumbar  fascia,  434.     (430) 

Divide  the  vertebral  aponeurosis  and  lumbar  fascia  by  an  incision  about  an  inch  from,  and  parallel 
with,  the  spinous  processes ;  reflect  outward  and  expose  the  erector  spinre  and  its  divisions. 

Erector  spinae,  440-1  ;  Fig.  306.     (436) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Outer  Division,  441-2-3.     (436-7-8) 
Ilio-costalis,  or  sacro-lumbalis  : — 

Origin.     Insertion. 
Accessorius  ad  ilio-costalis  or  ad  sacro-lumbalis. 

Origin.     Insertion. 
Cervicalis  ascendens  : — 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
Middle  Division  ;  443-4-5.     (438-9-40) 
Longissimus  dorsi  :  — 

Origin.     Insertion  ;  externally,  internally. 
Transversalis  colli  : — 

Origin.     Insertion. 


60  OUTLINES  OF  ANATOMY. 

Erector  Spinae — Middle  Division  : — 
Trachelo-mastoid :  — 

Origin.     Insertion. 
Structure  of  the  middle  division.     Nerve-supply.     Action.     Relations. 

Inner  division,  445.     (440-1) 
Spinalis  dorsi : — 

Origin.    Insertion.   Structure.    Nerve-supply.    Action.     Relations. 

Variations  of  the  erector  spinas  and  its  divisions. 

Divide  the  trachelo-mastoid  about  two  inches  below  its  insertion,  reflect  the  lower  portion  of  the  muscle 
to  the  origin,  then  remove  it ;  carefully  raise  the  upper  portion  and  expose  the  occipital  artery  in  the 
second  part  of  its  course. 

The  occipital  artery : — 

Second  part  of  its  course,  518-19-20.     (511-12) 
Branches: — Mastoid  branch. 

Princeps  cervicis,  superficial  branch. 
Muscular  branches. 
Complexus,  446;  Fig.  306.     (441) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  complexus  transversely  near  the  middle,  carefully  raise  and  reflect  each  portion,  noting  the 
nerves  passing  through  it.  Expose  the  deep  branch  of  the  princeps  cervicis,  and  the  posterior  divisions 
of  the  spinal  nerves. 

Princeps  cervicis,  deep  branch,  520.     (511-12) 

Deep  cervical  branch — from  the  superior  intercostal,  551  ;  Fig.  342.     (541) 
Deep  cervical  vein,  652.     (639) 

Posterior  primary  divisions  of  the  spinal  nerves,  825-6-7-8  ;  Fig.  452.  (806-7-8-9) 
Cervical  nerves:  — 

Internal  branches.     External  branches. 
Posterior  division  of  the  second  cervical  nerve. 

Great  occipital  nerve. 
Thoracic  nerves: — Internal  branches. 
External  branches. 
Lumbar  nerves: — Internal  branches. 

External  branches — of  the  upper  three  nerves, 
of  the  fourth  lumbar  nerve, 
of  the  fifth  lumbar  nerve. 

Arteries  of  the  cervical,  thoracic,  and  lumbar  regions : — 
Cervical  region : — 

Princeps  cervicis,  520.     (511-12) 
Deep  cervical  branch,  551.     (541) 

Muscular  branches,  from  the  second  portion  of  the  vertebral,  542.  (532) 
Thoracic  region  : — From  intercostal  arteries  : — 

Dorsal  branch,  582;  Fig.  362.     (571-2) 
(ii)  Muscular  branch. 
Lumbar  region  : — From  lumbar  arteries  : — 

Dorsal  branch,  588.     (577) 

The  veins  accompany  the  arteries  and  terminate  in  the  intercostal  or  lumbar  veins,  in 
the  thoracic  or  lumbar  regions. 

Demonstrate  the  middle  layer  of  the  lumbar  fascia,  434.  (430).  Divide  the  erector  spins  at  its  origin 
and  remove  the  muscle,  together  with  its  divisions,  in  order  to  expose  the  underlying  muscles  to  advantage. 

Semispinalis  dorsi,  446-7—8;  Fig.  308.     (443) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
Semispinalis  colli,  448  ;  Fig.  308.  (443) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations. 
Multifidus  spinae,  448;  Fig.  308.  (443-4) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Follow  the  branches  of  the  sacral  and  coccygeal  nerves  through  the  multifidus  spinae,  cutting  away  the 
muscle  to  expose  the  nerves.  The  entire  muscle  should  then  be  removed. 


HEAD  AND  ANTERIOR    CERVICAL   STRUCTURES. 


61 


Sacral  and  coccygeal  nerves,  828.     (808-9) 

Internal  branches.     External  branches. 
Lower  two  sacral  and  the  coccygeal  nerve. 
Rotatores  spinae,  449.     (444) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Interspinales,  449-5°-     (444) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Intertransversales,  449-50.     (445) 

Structure.     Nerve-supply.     Relations. 
Levatores  costarum,  421  :  Fig.  299.     (418) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Ligamentum  nuchae,  1250.     (1226) 
Spinal  veins,  667-8;  Fig.  390.     (653-4) 
Extraspinal  and  intraspinal. 

The  extraspinal  veins: — 
Anterior  spinal  plexus. 
Posterior  spinal  or  dorsal  spinal  plexus. 

In  the  suboccipital  triangle  trace  the  branches  and  expose  the  posterior  primary  division  of  the  first  cer- 
vical nerve. 


(806-7) 


Action.  Relations. 

Action.  Relations. 

Action.  Relations. 

Action.  Relations. 

Action.  Relations. 


Posterior  primary  division  of  the  first  cervical  nerve,  826-7. 
The  Suboccipital  Muscles,  450-1 ;  Fig.  308.     (445-6) 
Rectus  capitis  posticus  major  : — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Rectus  capitis  posticus  minor:  — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Obliquus  capitis  inferior: — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Obliquus  capitis  superior: — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Rectus  capitis  lateralis,  Fig.  316. 

Origin.     Insertion.     Structure.     Nerve-supply. 

Variations. 

Vertebral  artery,  540;  Fig.  342.     (532) 

The  second  or  vertebral  portion. 
Vertebral  artery,  540-1  ;  Fig.  342.     (532;. 
The  third  or  occipital  portion. 

In  front.     Behind. 

Branches  of  the  occipital  artery,  520  ;  Fig.  335.     (511-12) 
Communicating. 

Clean  away  the  muscles,  exposing  the  laminae  of  the  vertebrae.  Saw  through  the  laminae  of  the  verte- 
brae close  to  the  inner  side  of  the  articular  processes.  Divide  the  ligamenta  subflava  and  remove  the 
posterior  wall  of  the  spinal  canal,  exposing  the  cord  inclosed  in  its  membranes. 

The  spinal  arteries  are  derived  from: — 

Vertebral  arteries ; 

Lateral  spinal  branches,  542.     (532) 
Intercostal  arteries ; 

Spinal  branch,  582.     (571) 
Lumbar  arteries  : 

Dorsal  branch,  588.     (577) 
The  intraspinal  veins,  668  ;  Fig.  390.     (654-5) 

Meningeal  extra-medullary  or  meningo-rachidian  veins  : — 

Anterior  longitudinal  spinal  veins  (exposed  later). 
Posterior  longitudinal  spinal  veins. 

The  Spinal  Cord,  Spinal  nerves,  etc. 

The  spinal  cord,  771.     (754) 

The  dura  mater,  772-3  j  Figs.  435~6-     (755~6) 

Open  the  dural  sheath  by  a  median  incision,  and  expose  the  arachnoid. 


62  OUTLINES  OF  ANATOMY. 

The  arachnoid,  773  ;  Fig.  436.     (756) 
The  subarachnoid  tissue,  774.      (757) 

Remove  the  arachnoid  from  a  small  portion  of  the  cord  and  expose  the  pia  mater. 

The  pia  mater,  774.     (757) 

Ligamentum  denticulatum,  774;  Fig.  435.     (757) 

External  characteristics  of  the  spinal  cord,  774-6.     (757-9) 

Conus  medullaris.     Cervical  enlargement. 

Lumbar  enlargement.     Cauda  equina. 

Demonstrate  the  origin  of  one  or  two  of  the  spinal  nerves.  With  a  pair  of  strong  pliers,  cut  away  the 
bone  and  expose  them  in  their  passage  through  the  intervertebral  foramina ;  expose  also  their  termina- 
tion into  anterior  and  posterior  primary  divisions. 

The  spinal  nerves,  822-3-5  ;  Fig.  436-7.     (803-4-5-6) 
Anterior  roots. 
Posterior  roots. 

Course  and  direction.     Cauda  equina. 
Classification  and  number. 
General  distribution :  — 

Posterior  primary  divisions. 

Anterior  primary  divisions. 

Remove  the  spinal  cord  with  its  membranes.  Review  the  relations  and  structure  of  the  membranes 
and  demonstrate  the  origin  of  the  spinal  nerves  in  the  manner  indicated,  see  Dissection,  771-2.  (754-5) 
When  the  cord  is  removed,  the  anterior  longitudinal  spinal  veins  can  be  demonstrated. 

Membranes  of  the  cord  and  ligamentum  denticulatum,  772-3-4.     (735-6-7) 
External  characteristics  of  the  spinal  cord,  774-6.     (757-9) 
Expose  and  demonstrate  the  fissures  of  the  cord. 

Fissures,  776;  Fig.  438.     (759) 
Anterior  longitudinal  fissure. 
Posterior  longitudinal  fissure. 

Antero-lateral  and  postero-lateral  fissures  or  grooves. 
Columns : — 

Anterior. 

Lateral. 

Posterior. 

Make  a  number  of  transverse  sections  to  exhibit  the  internal  structure  of  the  cord,  Fig.  439. 
Internal  structure  of  the  cord,  776-7-8.     (759-60-1) 

The  student  should  read  the  chapter  on  The  Deep  Origin  of  the  Spinal  Nerves,  pages  778-86.  (761-68) 
The  minute  structure  of  the  spinal  cord  and  the  deep  origin  of  the  spinal  nerves  can  be  studied  to  ad- 
vantage only  with  specially  prepared  and  mounted  sections  and  with  the  aid  of  the  microscope.  This 
should  be  done  in  the  Histological,  or  Brain  Laboratory. 


THE  UPPER  EXTREMITY. 

Landmarks  of  the  Thoracic  Region,  Shoulder,  and  Axilla. 
Superficial  Anatomy  of  the  Thorax,  1134  to  1140.     (nit  to  1118) 
Bony  points : — 

Sterno-clavicular  joint. 

Acromio-clavicular  joint. 

Ribs. 

The  mamma. 

Structures  found  in  an  intercostal  space. 
Parts  behind  the  manubrium. 
Outline  of  the  lungs: — 

Their  relation  to  the  chest  wall.     The  pleura. 
Outline  of  the  heart : — 

Its  relation  to  the  chest  wall. 

The  valves. 


THE    UPPER   EXTREMITY.  63 

Outline  of  the  Heart — the  Valves:  — 
Pulmonary  valves. 
Aortic  valves. 

Auriculo-ventricular  openings. 
Tricuspid  valves. 
Mitral  valves. 
Relation  of  the  vessels  to  the  wall  of  the  thorax.     Aortic  arch. 

Innominate  artery.     Left  common  carotid.     Left  subclavian  artery. 
Innominate  veins,  left,  right. 
Venae  cavae : — 

Superior.     Inferior  vena  cava. 
Internal  mammary  artery. 

Shoulder  and  Axilla,  1180  to  1184.     (1156  to  1160) 
Surface  marks : — 

Clavicle.     Acromion  process. 

Great  tuberosity  and  upper  part  of  shaft  of  humerus.      • 
Coracoid  process.     Head  of  humerus.     Clavicle. 
Bicipital  groove. 

Characteristic  roundness  of  the  shoulder.     Deltoid. 
Pectoralis  major.     Pectoralis  minor.     Coraco-brachialis. 
Axilla. 
Dissection  of  the  External  Thoracic  Region  and  Axilla. 

Make  a  median  incision  from  the  upper  to  the  lower  end  of  the  sternum,  and  three  transverse  incisions  : 
the  first,  from  the  sternum  outward  along  the  anterior  border  of  the  clavicle,  and  downward  in  the 
anterior  median  line  of  the  arm;  the  second,  from  the  lower  end  of  the  sternum  outward  and  upward 
along  the  lower  border  of  the  pectoralis  major  to  the  arm,  joining  the  first  incision  ;  the  third,  from  the 
lower  end  of  the  sternum  outward  and  backward  to  the  lower  end  of  the  scapula.  Beginning  at  the 
median  line,  reflect  the  skin  outward.  Expose  the  superficial  fascia  of  the  pectoral  region,  axilla,  and 
upper  third  of  arm.  Expose  the  superficial  nerves  and  vessels  of  the  thoracic  wall.  At  the  upper  part 
of  the  thorax  note  the  fibres  of  origin  of  the  platysma. 

The  superficial  fascia,  308.     (311) 
Platysma  myoides,  452.     (447) 

Origin.     Structure. 
Superficial  nerves : — 

Descending  branches — of  cervical  nerves,  831.     (812) 
Suprasternal  twigs. 
Supraclavicular  nerves. 
Supra-acrominal  branches. 

Anterior  cutaneous  nerves  of  the  thorax,  845.     (826) 
Lateral  cutaneous  nerves  of  the  thorax,  845.     (825) 

Anterior  branches.     Posterior  branches. 

The  superficial  arteries  of  the  thoracic  region  are  small  branches  from : — 
The  internal  mammary,  549-50;  Fig.  344.     (540) 

Perforating  or  anterior  perforating  branches. 
Second,  third,  and  fourth  perforating. 
The  intercostal  arteries,  583  ;  Fig.  362.     (572) 
Lateral  cutaneous  branches. 
Mammary  glandular  branches. 
Lymphatics  of  the  thorax,  695  ;  Fig.  399.     (680) 
Parietal  lymphatic  vessels,  695-6. 
Superficial  parietal  lymphatics. 
Lymphatics  of  the  mammary  gland. 
Superficial  parietal  glands.     Epigastric  gland. 

If  a  female  subject,  remove  the  mammary  gland  and  demonstrate  its  structure. 
The  mammary  glands,  1108-9-10;  Figs.  657-8.     (1084-5-6-7) 
Female  mamma  : — Mammilla,  or  nipple.     Areola. 
Secreting  organ,  structure  of: — Adipose  fossae.     Sinus  or  ampulla. 
Mammilla.     Areola. 
Variations  according  to  age  and  functional  activity. 


64  OUTLINES  OF  ANATOMY. 

The  Mammary  Glands — 

Vessels  and  nerves  : — 

Arteries.     Veins.     Lymphatics.     Nerves. 

Development.     Abnormalities.     Nipples. 

Dissect  off  the  superficial  fascia  and  expose  the  pectoral  fascia,  and  deep  fascia  of  the  upper  third  of  the 
arm. 

Pectoral  fascia,  308-9.     (311) 

Deep  fascia — of  arm,  321-2.     (323-4) 

Reflect  the  deep  fascia  from  the  surface  of  the  pectoralis  major  by  dissecting  parallel  with  the  course 
of  its  fibres.  Expose  also  the  anterior  portion  of  the  deltoid  and  remove  the  deep  fascia  from  the 
upper  third  of  the  front  of  the  arm. 

Pectoralis  major,  309-10-11  ;  Fig.  264.     (311-12-13) 

Origin.     Insertion.     Structure  ;  clavicular,  sterno-costal  portion. 
Nerve-supply.     Action.     Relations.     Variations. 

In  the  interval  between  the  pectoralis  major  and  deltoid,  exposed  by  separating  the  contiguous 
borders  of  the  muscles,  are  the  cephalic  vein  and  the  humeral  branch  of  the  acromio-thoracic  artery. 

Cephalic  vein,  680-1  ;  Fig.  396.     (666) 

Humeral  branch — of  the  acromio-thoracic  artery,  555.     (545) 

Carefully  reflect  the  clavicular  portion  of  the  pectoralis  major  by  detaching  it  from  the  clavicle  and 
turning  it  downward ;  note  the  branches  of  the  external  anterior  thoracic  nerve  entering  its  deep  sur- 
face. The  clavi-pectoral  fascia  should  be  carefully  exposed  in  the  interval  between  the  clavicle  and 
the  pectoralis  minor,  and  its  connections  and  relations  noted. 

Clavi-pectoral  fascia,  costo-coracoid  membrane,  308.     (311) 

Remove  the  costo-coracoid  membrane  and  expose  the  subclavius  muscle.  Trace  the  cephalic  vein  to 
its  termination  and  expose  that  portion  of  the  axillary  vein  between  the  clavicle  and  the  upper  border 
of  the  pectoralis  minor.  Also,  the  first  portion  of  the  axillery  artery  and  that  part  of  the  brachial 
plexus  in  relation  with  the  vessels.  Note  the  thoracic  branches  of  the  brachial  plexus  crossing  in  front 
of  the  vessels  to  the  pectoral  muscles.  Demonstrate  the  thoracic  axis  and  its  branches  and  expose  the 
-  origin  of  the  superior  thoracic  artery. 

Sublcavius,  311-12-13;  Fig,  265.     (313-14) 

Origin.     Insertion.     Structure.     Nerve-supply.    Action.    Relations.  Variations. 
Axillary  vein,  682.     (668) 
The  axillary  artery,  552.      (542) 

First  part  of  the  axillary  artery  : — 

Relations  : — In  front.     Behind.     Outer  side.     Inner  side. 
Branches  of  the  first  part  of  the  axillary  artery,  555.     (543-5) 
Acromio-thoracic  or  thoracic  axis  : — 
Acromial  branch. 
Pectoral  branch. 
Clavicular  branch. 
Superior  or  short  thoracic. 
External  anterior  thoracic  nerve,  835.     (815) 
Internal  anterior  thoracic  nerve,  835.     (815) 

Turn  off  the  superficial  fascia  of  the  axilla,  exposing  the  deep  fascia  or  axillary  fascia. 
Axillary  fascia,  308-9.     (311) 

Beginning  at  the  anterior  border  of  the  axilla,  separate  the  deep  fascia  from  the  lower  border  of  the  pec- 
toralis major  and  carefully  reflect  it  backward  to  the  posterior  border  of  the  space.  In  the  reflection 
of  the  fascia  care  must  be  exercised  not  to  injure  the  lateral  cutaneous  branches  of  the  second  and  third 
intercostal  nerves. 

Intercosto-humeral  nerve,  845  ;  Fig.  460.     (825) 

Lateral  cutaneous  branch  of  the  third  intercostal,  845.     (825-6) 

Axillary  glands,  695  ;  Fig.  399.     (679-80) 

Carefully  dissect  out  the  lymphatics,  fat,  and  connective  tissue,  exposing  the  third  portion  of  the  axillary 
artery  and  the  divisions  of  the  brachial  plexus  in  relation  with  it. 

Third  part  of  the  axillary  artery,  553.     (543) 

Relations: — In  front.     Behind.     Outer  side.     Inner  side. 


THE   UPPER  EXTREMITY.  65 

Divide  the  pectoralis  major  near  the  middle,  turn  the  outer  portion  to  the  insertion;  reflect  the  inner 
portion  to  the  origin.     Preserve  the  arteries,  so  far  as  possible,  in  connection  with  the  main  trunks. 

Pectoralis  minor,  313;  Fig.  266.     (314-15-16) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Second  part  of  the  axillary  artery,  552-3.     (542-3) 

Relations  : — In  front.     Behind.     Inner  side.     Outer  side. 

Divide  the  pectoralis  minor  near  the  middle  and  turn  to  its  origin  and  insertion.     The  subclavius  should 
also   be  divided  at  its  insertion  and  thrown  in  toward  its  origin.     The  axillary  artery  will  be  fully 
exposed  throughout  its  course;  its  relations  should  be  reviewed  and  the  branches  demonstrated. 
Relations  of: — First  part  of  axillary  artery,  552.     (542) 

Second  pan  of  axillary  artery,  552-3.     (542-3) 
Third  part  of  axillary  artery,  553.     (543) 
Chief  variations  in  the  axillary  artery,  553.     (543) 
Branches  of  the  first  part  of  the  axillary  artery,  555. 
Superior  or  short  thoracic. 
Acromio  thoracic  or  thoracic  axis  : — 

Acromial  branch.     Humeral  branch. 
Pectoral  branch.     Clavicular  branch. 

Branches  of  the  second  part  of  the  axillary  artery,  555.     (545) 
Long  thoracic  artery. 
Alar  thoracic. 

Branches  of  the  third  part  of  the  axillary  artery,  555-6-7-8.     (545-6-7-8 ) 
Subscapular  artery  : — 
Dorsal  scapular. 
Infrascapular. 

Chief  variations  in  the  subscapular  artery. 
Anterior  circumflex : — 

Branches : — Bicipital. 
Pectoral. 
Chief  variations. 

Posterior  circumflex : — 
Branches : — Nutrient. 
Acromial. 
Muscular. 

Chief  variations  in  the  posterior  circumflex. 
Axillary  vein,  682.     (668) 

Remove  the  middle  third  of  the  clavicle.     Dissect  off  the  fascia  and  connective  tissue  and  expose  the 
nerves  of  origin,  trunks,  divisions,  cords,  and  terminal  branches  of  the  brachial  plexus. 

The  brachial  plexus,  832-3-4;  Fig.  455.     (813-14) 

The  brachial  plexus  is  formed  by  the  anterior  primary  divisions  of: — 
Four  lower  cervical  nerves. 
First  thoracic  nerve. 

Usually  joined  by  communicating  branches  from: — 
Fourth  cervical  and  second  thoracic  nerves. 
The  brachial  plexus  is  divisible  into  four  stages  : — 

First  stage  : — All  the  component  nerves  are  separate  from  each  other. 

Four  lower  cervical  and  first  thoracic  nerve. 
Second  stage: — Nerves  unite  with  one  another  to  form  trunks. 

Upper  trunk.     Middle  trunk.     Lower  trunk. 

Third  stage: — Trunks  divided  into  three  anterior  and  three  posterior  divi- 
sions. 
Fourth  stage : — Three  posterior  divisions  unite  to  form  posterior  cord. 

Anterior  divisions  of  upper  and  middle  trunks  unite  to  form 
outer  cord. 

Anterior  division  of  inner  trunk  continued  as  inner  cord. 
Position  of: — The  first  stage  of  the  plexus. 

Second  stage.     Third  stage.     Fourth  stage. 


66  OUTLINES   OF  ANATOMY. 

Trace  the  branches  of  the  brachial  plexus  through  the  region,  or  from  their  origin  to  the  point 
where  they  pass  into  or  under  other  structures.  The  terminal  distribution  of  each  branch  will  be 
demonstrated  later,  during  the  process  of  the  dissection. 

'  Branches  of  the  brachial  plexus  : — 

Branches  given  off  above  the  clavicle,  834-5.     (814-15) 
Suprascapular  nerve.     Nerve  to  rhomboids. 
Posterior  thoracic  nerve.     Communicating  twig  to  phrenic. 
Nerve  to  subclavius. 
Branches  given  off  below  the  clavicle  : — 

Axillary  or  short  branches,  835.     (815-16) 
External  anterior  thoracic. 
Internal  anterior  thoracic. 
Subscapular  nerves : — 

Upper  or  short  subscapular  nerve. 
Middle  or  long  subscapular  nerve. 
Lower  subscapular  nerve. 
Terminal  or  long  branches  :   835. 
From  outer  cord  :  — 

Musculo-cutaneous  and  outer  head  of  median. 
From  inner  cord  :  — 

Inner  head  of  median.     Ulnar.     Internal  cutaneous 
and  lesser  internal  cutaneous. 
From  posterior  cord  : — 

Musculo-spiral  and  circumflex. 

The  dissector  of  the  tipper  extremity  should  participate  in  the  dissection  of  the  back, 
until  the  dissection  of  the  serratus  magnus  is  completed.     (See  pages  58,  59) 

The  Shoulder. 

Note  the  distribution  of  the  cutaneous  nerves,  Fig.  456;  P.  836.     (817) 

Remove  the  skin  from  the  shoulder  and  the  upper  half  of  the  arm,  and  expose  the  superficial  fascia  and 
the  nerves. 

Superficial  fascia,  315.     (318) 
Superficial  nerves: — 

Supra-acromial  branches,  831.     (812) 

Cutaneous  branches — of  the  circumflex  nerve,  835.     (816) 
Anterior  division.     Posterior  division. 

Turn  off  the  superficial  fascia  and  expose  the  deep  fascia. 

The  deep  fascia,  315.     (318) 

Remove  the  deep  fascia  and  expose  the  deltoid. 

Deltoid  muscle,  316-17;  Figs.  262  and  264.     (318-19) 

Origin.     Insertion.     Structure.    Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  deltoid  at  its  origin  and  turn  it  down  to  the  insertion.     Note  the  vessels  and  nerves  entering 
its  deep  surface. 

Posterior  circumflex  artery,  557-8;  Fig.  348.     (547-8) 

Branches: — Nutrient.     Articular.     Acromial.     Muscular. 

Chief  variations  in  the  posterior  circumflex. 

Circumflex  nerve,  835.     (816) 

Anterior  division.     Posterior  division. 
Anterior  circumflex  artery,  557.     (546-7) 

Branches : — Pectoral.     Bicipital. 

Chief  variations. 
Turn  off  the  deep  fascia  covering  the  infra- spinatus,  teres,  and  supra- spinatus. 

Infra-spinatus,  317-18;  Fig.  268.     (319-20-1) 

Origin.    Insertion.     Structure.     Nerve-supply.    Action.    Relations.    Variations. 
Teres  minor,  319;  Fig.  268.     (321) 

Origin.    Insertion.    Structure.    Nerve-supply.     Action.    Relations. 


THE    UPPER  EXTREMITY.  67 

Teres  major,  320-1  ;  Figs.  268-9.     (322~3) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations. 

Cut  away  the  outer  portion  of  the  acromion  process  and  expose  the  supra-spinatus. 

Supra-spinatus,  317  ;  Fig.  268.     (319) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.     Relations.    Variations. 
Subscapularis  muscle,  319-20  ;  Fig.  269.     (321-2) 

Origin.    Insertion.    Structure.    Nerve-supply.     Action.    Relations.    Variations. 

Carefully  raise  the  supra-spinatus,  infra-spinatus,  and  subscapularis  from  the  scapula  and  expose  the 
vessels  and  nerves  passing  under  them. 

Posterior  scapular,  547-8;  Fig.  343.     (538) 

Branches: — Supraspinous.     Infraspinous  branches.     Subscapular  branches. 
Suprascapular  artery,  546  ;  Fig.  343.     (536-7) 

Branches  of  the  suprascapular. 
Suprascapular  nerve,  834.     (814-15) 
Subscapular  artery,  555-6-7  ;  Fig.  343.     (545 -6) 

Branches: — Dorsal  scapular.     Infrascapular. 

Chief  variations  in  the  Subscapular  artery. 

Landmarks  of  the  Arm,  Elbow,  and  Forearm. 
The  Arm,  1186-7-8.     (1162-3-4) 
The  shaft  of  the  humerus.     Biceps.     Brachial  artery. 
Centre  of  the  arm. 
Brachialis  anticus. 
Median  nerve. 
Ulnar  nerve. 
Musculo-spiral  nerve. 

The  Elbow,  1188-9-90-1.     (1164-5-6-7) 
Bony  points. 

Hollow  in  front  of  the  elbow. 
M-like  arrangement  of  the  superficial  veins. 
The  Forearm,  1193-4-5-6-7.     (1168-9-70-1-2) 
Bony  landmarks. 
Soft  parts.     Ulnar  artery.     Ulnar  nerve.     Median  nerve. 

Radial  artery.     Radial  nerve. 

Anterior  interosseous  artery. 

Posterior  interosseous. 

Dissection  of  the  Arm  and  Forearm. 

Outline  the  superficial  nerve  supply  of  the  arm  and  forearm,  Fig.  456  ;  P.  836.   (817) 

In  order  to  expose  the  superficial  nerves  and  veins  to  the  best  advantage,  remove  the  skin  from  the  arm 
and  reflect  it  from  the  forearm.  To  do  this,  continue  the  anterior  median  incision  to  the  wrist,  make  a 
circular  incision  about  two  inches  below  the  elbow  and  remove  the  skin  from  the  arm  above  that  point. 
Make  a  transverse  incision  at  the  wrist,  reflect  the  skin  of  the  forearm  each  way  from  the  median  inci- 
sion to  the  posterior  surface.  On  the  posterior  surface,  beginning  near  the  elbow,  turn  it  toward  the 
hand  to  the  wrist.  The  skin  of  the  forearm  should  not  be  removed,  but  preserved  as  a  cover  for  the 
muscles  after  the  nerves  and  veins  are  exposed,  until  the  dissection  of  the  arm  is  completed. 

Superficial  nerves  of  the  arm  and  forearm,  Fig.  456;  P.  836.     (817) 
Outer  side : — 

Posterior  division  of  the  circumflex,  835. 

External  cutaneous  branches  of  the  musculo-spiral,  841.     (821-2) 

Upper  branch.     Lower  branch. 
Musculo-cutaneous,  837-8.     (816-17) 

Anterior  branch.     Posterior  terminal  branch. 
Inner  side  : — 

Intercosto-humeral,  845.     (825) 

Internal  cutaneous  branch  of  musculo-spiral  nerve.  841.     (821) 
Lesser  internal  cutaneous  nerve  or  nerve  of  Wrisberg,  835-6.     (816) 
Internal  cutaneous,  836. 

Anterior  branch.     Posterior  branch. 


68  OUTLINES  OF  ANATOMY. 

Veins  of  the  upper  limb,  superficial  and  deep,  678.     (664) 
Superficial  veins,  678;  Fig.  396.     (664-5) 
Superficial  radial. 

The  anterior  and  posterior  superficial  ulnar  veins  unite  to  form  a  single 
superficial  ulnar  vein. 
Superficial  median  vein  : — 
Divides  into : — 

Median  cephalic — which  unites  with  the  superficial  radial  to  form 

the  cephalic. 

Median  basilic — which  unites  with  the  superficial  ulnar  to  form  the 
basilic.     (665) 

The  basilic  joins  with  the  inner   brachial  vena 
comes  to  form  the  axillary  vein,  679.     (665) 
Superficial  median  vein,  deep  median  vein,  679.     (665) 
Median  basilic  vein,  680.     (666) 

Anterior  superficial  ulnar,  679.     (665) 
Posterior  superficial  ulnar,  679.     (665) 

Basilic  vein,  681-2.     (666-7) 
Median  cephalic  vein,  679-80.     (665) 

Superficial  radial  vein,  679.     (665) 

Cephalic  vein,  680-1.     (666) 
Lymphatics  of  the  upper  extremity,  693.     (678) 

Superficial  lymphatic  vessels,  693  ;  Fig.  399.     (678) 
Superficial  lymphatic  glands,  693.     (678) 

Replace  the  skin  of  the  forearm  and  bandage  it  in  position  until  the  dissection  of  the  arm  is  completed. 
Remove  the  superficial  fascia  from  the  arm  and  upper  two  inches  of  the  forearm. 

The  deep  fascia,  321-2.     (323-4) 

Divide  the  deep  fascia  in  the  median  line  and  turn  it  out  and  in  from  the  median  incision,  exposing  the 
biceps.  The  intermuscular  septa  should  be  demonstrated  as  the  dissection  proceeds.  Push  aside  the 
inner  border  of  the  biceps,  dissect  off  the  sheath  and  expose  the  brachial  vessels  in  place. 

The  brachial  artery,  559-60-1 ;  Figs.  350-1.     (548-9-50-1) 
Relations  : — In  front.     Behind.     External.     Internal. 

Chief  variations  in  the  brachial  artery. 

Branches,  561-2-3.     (551-2-3) 
Superior  profunda,  (origin). 
Inferior  profunda,  chief  variations. 
Anastomotica  magna  : — 

Branches: — Anterior.     Posterior. 

Chief  variations. 

Nutrient  artery  of  the  humerus. 
Muscular  branches. 
Deep  veins  of  the  upper  extremity,  682.     (668) 

Brachial  venae  comites. 
Deep  lymphatic  vessels,  693-4-5.     (678) 
Deep  lymphatic  glands,  695.     (678) 
Median  nerve,  838.     (817-18-19) 
Internal  cutaneous  nerve,  836.     (816) 
Lesser  internal  cutaneous  nerve,  835-6.     (816) 
Ulnar  nerve,  840.     (820) 
Musculo-cutaneous  nerve,  837.     (816-17) 
Nerves  to  the  coraco-brachialis. 
Nerves  to  the  biceps  and  brachialis  anticus  muscles. 
Coraco-brachialis,  321 ;  Figs.  270-1.     (323) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations.     Variations. 
Biceps,  323-4  ;  Fig.  270.     (325-6) 

Origin,  long  head,  short  head.     Structure.     Nerve-supply. 
Action.     Relations.     Variations. 


THE    UPPER  EXTREMITY. 


69 


Brachialis  anticus,  325;  Fig.  270.     (326-7) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.     Relations.     Variations. 

Remove  the  deep  fascia  from  the  posterior  surface  of  the  arm  and  expose  the  triceps.  Trace  the  mus- 
culo  spiral  nerve  and  the  superior  profunda  artery. 

Triceps  extensor  cubiti,  326-7  ;  Fig.  268.     (327-8-9) 

Origin,  long  head,  external  head,  internal  head.     Insertion. 
Structure.     Nerve-supply.     Action.     Relations.     Variations. 
Musculo-spiral  nerve,  841.     (821-2) 

Branches  : — Internal  cutaneous  branch. 

External  cutaneous  branches : 

Upper  branch.     Lower  branch. 

Nerve  to  the  long  head.     Nerves  to  the  outer  and  inner  heads. 
Nerve  to  the  anconeus. 
Nerves  to  the  brachialis  anticus,  supinator  longus  and  extensor  carpi 

radialis  longior. 
Superior  profunda  artery,  562.     (551-2) 

Branches: — Ascending  branch.     Cutaneous  branch.     Articular  branch. 
Nutrient  artery.     Muscular  branches. 

Chief  variations. 

Forearm. 

Remove  the  skin  and  superficial  fascia  to  the  wrist. 

Deep  fascia,  327-8.     (329) 
Anterior  annular  ligament. 

The  deep  fascia  of  the  lower  portion  of  the  forearm,  above  the  annular  ligament,  should  be  carefully 
reflected  from  the  surface  of  the  muscles.  Care  must  be  exercised  not  to  remove  the  cutaneous  nerve 
branches  which  pierce  the  deep  fascia  near  the  wrist  and  pass  for  distribution  to  the  palmar  and  dorsal 
suriaces  of  the  hand.  At  the  upper  part  of  the  forearm  near  the  internal  condyle,  the  deep  surface  of 
the  fascia  gives  origin  to  muscles  and  cannot  be  removed  without  injury  to  the  muscles.  The  muscles 
should  be  carefully  exposed  and  separated  and  the  vessels  and  nerves  displayed. 

Brachio-radialis  or  supinator  radii  longus,  339  ;  Fig.  272.     (340) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.     Relations.     Variations. 

That  part  of  the  brachio-radialis  in  relation  with  the  radial  artery  should  be  raised  and  pushed  aside  to 
expose  the  vessel.  The  muscle  will  be  considered  later. 

The  radial  artery,  571  ;  Fig.  355.     (561) 

The  radial  artery  in  the  forearm,  571-2.     (562-3) 

Relations: — In  front.     Behind.     Outer  side.     Inner  side. 

Variations  in  the  radial  artery  in  the  forearm,  572-3.     (563) 

Branches  of  the  radial  artery  in  the  forearm,  573-4.     (563) 

Radial  recurrent.     Muscular  branches  of  the  radial  artery. 
Anterior  radial  carpal.     Superficial  volar. 
Radial  vein  accompanies  the  artery. 
Radial  nerve,  841-2.     (823) 
Pronator  radii  teres,  328-9-30  ;  Fig.  272.     (330-1) 

Origin.  Insertion.     Structure.     Nerve-supply.    Action. 
Flexor  carpi  radialis,  330-1  ;  Fig.  272.     (832) 

Origin.     Insertion.    Structure.     Nerve-supply.    Action.    Relations.    Variations. 
Palmaris  longus,  331 ;  Fig.  272.     (332) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.     Relations.    Variations. 
Flexor  carpi  ulnaris,  321-2;  Fig.  272.     (333) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.     Relations.    Variations. 
Flexor  sublimis  digitorum,  332-3-4-5  ;  Fig.  273. 

Origin.   (Insertion.)  Structure.    Nerve-supply. 
The  ulnar  artery,  563-4.     (553) 

Relations  of  the  ulnar  artery  in  the  forearm,  564-5.     (553-4) 
In  front.     Behind.     Outer  side.     Inner  side. 

Variations  of  the  ulnar  artery  in  the  forearm.     (555) 


Relations.    Variations. 


(334-5-6) 
Action.     Relations. 


Variations. 


7o  OUTLINES  OF  ANATOMY. 

Branches  of  the  ulnar  artery  in  the  forearm,  565-6-7-8.     (555-6-7) 
Anterior  ulnar  recurrent.     Posterior  ulnar  recurrent. 
Interosseous,  or  common  interosseous  artery. 
Muscular  branches  of  the  ulnar  artery. 
Nutrient  artery  of  the  ulna. 
Posterior  ulnar  carpal.     Anterior  ulnar  carpal. 
Ulnar  vein  accompanies  the  artery. 
Ulnar  nerve,  840.     (820—1) 

Branches : — Nerves  to  the  flexor  carpi  ulnaris  and  flexor  profundus  digitorum. 

Origin  of  palmar  cutaneous  and  dorsal  or  posterior  branch. 
Median  nerve,  838.     (817-18-19) 

Branches  : — Nerve  to  the  pronator  radii  teres. 

Nerves  to  the  flexor  carpi  radialis,  palmaris  longus,  and  flexor  sub- 

limis  digitorum. 

Origin  of — palmar  cutaneous  branch. 
Flexor  profundus  digitorum,  335-6-7  ;  Fig.   275.     (336-7-8) 

Origin.  (Insertion.    Structure.)    Nerve-supply.   Action.     Relations.    Variations. 
Flexor  longus  pollicis,  337-8  ;  Fig.  275.     (338-9) 

Origin.   (Insertion.)  Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Pronator  quadratus,  338  ;  Fig.  284.     (339) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.    Relations.     Variations. 
Anterior  interosseous  artery,  566.     (555-6-7) 

Branches  of  the  anterior  interosseous  artery  :  — 

Arteria  comes  nirvi  mediani,  or  median. 
Muscular  branches.     Nutrient  arteries. 
Anterior  terminal,  anterior  carpal  rete. 
Anterior  interosseous  nerve,  838.     (819) 

Landmarks  of  the  Wrist  and  Hand,  1198  to  1204.     1173  to  1180. 
Bony  points. 
Skin  folds. 

Thenar  and  hypothenar  eminences. 
Superficial  palmar  arch.     Deep  palmar  arch. 

Dissection  of  the  Wrist  and  Hand. 

Continue  the  median  incision  to  the  interval  between  the  second  and  third  ringers.  Make  a  transverse 
incision  at  the  base  of  the  fingers,  and  median  incisions  to  the  end  of  each  finger  and  the  thumb.  Turn 
the  skin  each  way  from  the  median  incisions. 

Cutaneous  nerves  of  the  palm  :  Fig.  456.     P.  836.     (P.  817) 

Palmar  cutaneous  branch  of  the  radial  nerve,  841-2.     (823) 
Palmar  cutaneous  branch — of  the  median  nerve,  838.     (819) 
Palmar  cutaneous  branch — of  the  ulnar  nerve,  840.     (821) 
Anterior  median  plexus — of  veins,  679.     (665) 
Palmaris  brevis,  352-3—4;  Fig.  280. 

Origin.    Insertion.     Structure.    Nerve-supply.    Action.     Relations.     Variations. 
Palmar  fascia,  351-2.     1206-7.     (1182) 
Outer  division,  or  thenar  fascia. 
Inner  division,  or  hypothenar  fascia. 

Divide  the  palmar  fascia  along  the  digital  border  of  the  annular  ligament,  leaving  the  ligament  in  place. 
Turn  the  fascia  forward  toward  the  fingers,  noting  its  relations  to  the  deeper  structures,  then  remove  it. 

The  ulnar  artery  at  the  wrist,  568.     (557-8) 

Relations  : — In  front.     Below.     Internally.     Externally. 
Superficial  branch,  superficial  palmar  arch,  568-9.     (558-9-60) 
Relations  : — In  front.     Behind. 

Variations  in  the  superficial  palmar  arch,  569-70.  .  (560) 
Branches  of  the  superficial  palmar  arch,  570-1.     (560) 
Digital  arteries: — 

First  digital  artery. 

Second,  third,  and  fourth  digital  arteries. 

Collateral  digital  arteries. 


THE    UPPER  EXTREMITY.  71 

Branches  of  the  Superficial  Palmar  Arch  :  — 

Muscular  branches. 

Cutaneous  branches. 

Deep  branch. 

Median  nerve,  838-9;  Fig.  458.     (817-18-19) 
Branch  to  the  muscles  of  the  thumb. 
External  terminal  division,  outer  branch,  inner  branch. 
Internal  terminal  division,  outer  branch,  inner  branch. 

Pacinian  corpuscles. 

Ulnar  nerve,  840  ;  Fig.  458.     (820-1) 

Superficial  terminal  branch  : — 

Inner  branch.     Outer  branch. 
Anterior  annular  ligament,  1204-5.     (1180— i) 

Synovial  membranes,  synovial  sacs,  1207-8—9.     (1182-3-4) 
Ligamenta  vaginialia,  352;  Figs.  279-80. 
Sheaths  of  the  flexor  tendons,  or  thecae,  352. 

Vincula  accessoria,  ligamentabrevia,  ligamenta  longa. 

Theca  of  thumb.     Theca  of  little  finger. 

Divide  the  anterior  annular  ligament  and  expose  the  structures  passing  underneath.  Open  the  sheaths 
of  the  tendons  and  trace  each  tendon  to  its  terminal  insertion. 

Flexor  sublimis  digitorum,  332-3-4-5  ;  Fig.  280.     (334-5-6) 

Insertion.     Structure.     Action.     Relations.     Variations. 
Flexor  longus  pollicis,  337-8.     (338—9) 

Insertion.     Structure.     Action.     Relations.     Variations.. 

Cut  the  ulnar  artery  just  below  the  deep  or  communicating  branch  and  throw  forward  the  superficial 
palmar  arch.  Divide  the  flexor  sublimis  digitorum  and  the  median  nerve  at  the  middle  of  the  forearm 
and  throw  forward,  exposing  the  flexor  profundus  digitorum  and  the  lumbricales. 

Flexor  profundus  digitorum,  335-6-7  ;  Figs.  279-80-3.     (336-7-8) 

Insertion.     Structure.     Action.     Relations.     Variations. 
Lumbricales,  354-576;  Figs.  283  and  279.     (354-5) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Muscles  of  the  thenar  eminence,  358. 

Abductor  pollicis,  358-9-60  ;  Fig.  280.     (358-9) 

Origin.  Insertion.  Structure.   Nerve-supply.  Action.  Relations.  Variations. 

Divide  the  abductor  pollicis  near  its  origin  and  turn  it  forward  to  the  insertion. 

Opponens  pollicis,  360  ;  Fig.  283. 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Flexor  brevis  pollicis,  360-1-2  ;  Figs.  283-4.     (360-1) 

Origin,  outer  head,  inner  head.     Insertion.     Structure. 

Nerve  supply,  outer  head,  inner  head.     Action.     Relations. 
Adductor  pollicis,  or  adductor  pollicis  transversus,  362  ;  Fig.  284.     (361-2) 

Origin.  Insertion.   Structure.   Nerve-supply.  Action.  Relations.  Variations. 
Muscles  of  the  hypothenar  eminence,  363.     (362) 
Abductor  minimi  digiti,  363  ;  Fig.  283.     (362) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Divide  the  abductor  minimi  digiti  near  its  origin  and  turn  forward  to  the  insertion. 

Flexor  brevis  minimi  digiti,  363;  Fig.  283. 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations.  Variations. 

Divide  the  flexor  brevis  minimi  digiti  at  its  origin  and  throw  forward  to  the  insertion. 

Opponens  minimi  digiti,  364;  Fig.  284.     (363) 

Origin.  Insertion.  Structure.   Nerve-supply.  Action.  Relations.  Variations. 
Deep  branch  of  the  ulnar  nerve,  840.     (821) 
Radial  artery  in  the  palm,  576.     (565-67) 

Variations  in  the  deep  palmar  arch. 


OUTLINES   OF  ANATOMY. 


Branches  of  the  deep  palmar  arch,  576-7-8-9  ;  Figs.  355  and  359.     (567-8) 
Princeps  pollicis.     Radialis  indicis. 
Palmar  interosseous  arteries. 
Recurrent  branches. 

Posterior  communicating  or  perforating. 
Back  of  the  forearm  and  hand. 

To  remove  the  skin  from  the  back  of  the  hand,  make  a  median  incision  from  the  wrist  to  the  interval 
between  the  second  and  third  fingers.  Make  a  transverse  incision  at  the  base  of  the  fingers,  and  median 
dorsal  incisions  to  the  end  of  each  finger  and  the  thumb.  Turn  the  skin  each  way  from  the  median 
incisions  and  remove. 

Cutaneous  nerves,  Fig.  459  ;  P.  842.     (822) 

Dorsal,  or  posterior  branch  of  the  ulnar  nerve,  840.     (821) 
Radial  nerve,  841-2.     (823) 

The  dorsal  surface  of  the  thumb,  and  of  the  first  second,  and  third  fingers,  re- 
ceive branches  from  the  terminal  divisions  of  the  median,  839.     (819) 
Nerve  supply  of  the  dorsal  integument  of  the  hand,  842-3.     (823) 
Dorsal  venous  plexus,  679.     (665) 

Digital  veins. 
Deep  fascia,  posterior  annular  ligament,  327-8.     (329) 

Dorsal  fascia,  351. 

Reflect  the  deep  fascia  from  the  posterior  surface  of  the  forearm  and  hand.  Preserve  the  posterior  an- 
nular ligament. 

Brachio-radialis,  or  supinator  radii  longus,  339;  Figs.  272  and  276.     (340) 

Origin.     Insertion.   Structure.    Nerve-supply.    Action.     Relations.    Variations. 
Extensor  carpi  radialis  longior,  341 ;  Figs.  276  and  275.     (340-1-2) 

Origin.    Insertion.     Structure.     Nerve-supply.    Action.    Relations.  Variations. 
Extensor  carpi  radialis  brevior,  341-2;  Fig.  276.     (342) 

Origin.  '  Insertion.     Structure.     Nerve-supply.    Action.    Relations.  Variations. 
Extensor  communis  digitorum,  342-3-4;  Figs.  276-7.    (343-4-5) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.    Relations.   Variations. 
Extensor  minimi  digiti,  344-5;  Figs.  276-7.     (345) 

Origin.     Insertion.    Structure.     Nerve-supply.    Action.     Relations.  Variations. 
Extensor  carpi  ulnaris,  345  ;  Fig.  276.     (345-6) 

Origin,  first  head,  second  head.     Insertion.     Structure. 

Nerve-supply.     Action.     Relations.     Variations. 
Anconeus,  345-6;  Figs.  276-8.     (346) 

Origin.    Insertion.     Structure.    Nerve-supply.    Action.     Relations.  Variations. 

To  expose  the  deeper  layer  of  muscles  detach  the  externus  carpi  ulnaris,  externus  minimi  digiti,  exter- 
nus  communicans  digitorum,  and  externus  carpus  radicis  brevior  at  their  origin  and  throw  forward. 
Note  the  vessels  and  nerves  entering  their  deep  surface. 

Extensor  ossis  metacarpi  pollicis,  348;  Fig.  278.     (348-9) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action. 
Extensor  brevis  pollicis,  349;  Fig.  278. 

Origin.     Insertion.    Structure.    Nerve-supply.    Action. 
Extensor  longus  pollicis,  349-50  ;  Fig.  278.     (350) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action. 
Extensor  indicis,  350-1  ;  Fig.  278. 

Origin.    Insertion.     Structure.     Nerve-supply.    Action. 


Relations.  Variations. 

Relations.  Variations. 

Relations.  Variations. 

Relations.  Variations. 


Divide  the  anconeus  at  its  origin  and  reflect  to  the  insertion. 
Expose  the  supinator  brevis. 

Supinator  radii  brevis,  346-7-8;  Fig.   278.     (346-7-8) 

Origin.    Insertion.     Structure.    Nerve-supply.    Action.    Relations.  Variations. 
Posterior  interosseous  artery,  566-7  ;  Fig.  353.     (557) 

Interosseous  recurrent,  or  posterior  interosseous  recurrent. 

Muscular  branches.     Articular  branches. 
Posterior  terminal — branch  of  anterior  interosseous  artery,  566.     (557) 

Posterior  carpal  rete. 
Posterior  interosseous  nerve,  841.     (823) 


THE    UPPER   EXTREMITY.  73 

Radial  artery  at  the  wrist,  574-5-6  ;  Fig.  358.      (563-4-5) 
Relations. 

Branches  of  the  radial  artery  at  the  wrist  : — 
Posterior  radial  carpal : — 

Second  and  third  dorsal  interosseous  arteries. 

Dorsal  digital  branches. 
Metacarpal,  or  first  dorsal  interosseous  artery  : — 

Dorsal  digital  arteries. 
Dorsalis  pollicis. 
Dorsalis  indicis. 

Open  and  demonstrate  the  compartments  of  the  posterior  annular  ligament. 

Posterior  annular  ligament,  1206.     (1181-2) 
Back  of  the  wrist  and  hand,  1210.     (1186) 
Transverse  ligament,  255  ;  Fig.  236.     (260) 

Divide  the  transverse  ligament,  separate  the  metatarsal  bones  and  expose  the  interossei  muscles  and  per- 
forating or  communicating  arteries. 

The  interossei,  356-7-8  ;  Figs.  281-2. 
Three  palmar  interossei : — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Four  dorsal  interossei :  — 

Origin.    Insertion.     Structure.    Xerve-supply. 
Action  of  the  interossei  muscles.     Relations.    Variations. 
Posterior,  communicating,  or  perforating  arteries,  579;  Fig.  359.    (568) 

The  muscles  of  the  shoulder,  arm,  forearm,  and  hand  should  now  be  removed.  On  the  forearm  re- 
move the  supinator  brevis  last.  The  removal  of  the  structures  should  be  made  a  process  of  careful  re- 
view, and  as  each  muscle  is  removed,  the  student  should  note  again  the  origin,  insertion,  structure, 
actions,  etc.,  especially  of  the  deeper  muscles,  which  are  fully  exposed  as  the  superficial  muscles  are 
removed.  Demonstrate  the  arterial  anastomoses  about  the  elbow  joint.  The  ligaments  of  the  joints 
should  then  be  exposed  and  demonstrated,  and  the  structure  of  the  joints  studied. 

Arterial  anastomoses  about  the  elbow  joint,  1191-2.     (116-7-8) 
Supinator  radii  brevis,  346-7.     (346-7-8) 
Origin.     Insertion.     Action. 

Articulations. 

The  various  kinds  of  articulations,  187—8.     (196—7) 
Synarthrosis  : — 
True  sutures. 
False  sutures. 
Grooved  sutures. 
Amphiarthrosis. 
Diarthrosis  :  — 
Arthrodia. 
Ginglymus. 

Ginglymo-arthrodial. 
Enarthrodia. 
Trochoides. 

The  various  movements  of  joints,  188-9.     (I97~8) 
Gliding. 
Angular. 
Rotation. 
Circumduction. 

Articulations  of  the  Upper  Extremity. 

Scapulo-clavicular  union,  230-1-2-3.     (236-7-8-9) 
(a)  Acromio-clavicular  articulation. 
(£)  Coraco-clavicular  ligaments. 
(c)  Proper  scapular  ligaments. 

Coraco-acromial  and  transverse. 
6 


74  OUTLINES   OF  ANATOMY. 

The  acromio-clavicular  joint. 

Class: — Diarthrosis.     Subdivision  \-Arthrodia. 
Capsular  ligament. 
Interarticular  fibro-cartilage. 
Synovial  membrane. 

The  coraco-clavicular  union. 

Coraco-clavicular  ligament : — 

Conoid  ligament. 

Trapezoid  ligament. 
Arterial  supply. 
Nerve-supply. 
Movements. 

The  proper  scapular  ligaments. 
Coraco-acromial  ligament : — 

Anterior  band. 

Posterior  band. 

Transverse,  coracoid,  or  suprascapular  ligament. 
Inferior  transverse,  or  spino-glenoid  ligament. 

The  shoulder  joint,  234-5-6-7-8.     (239-40-1-2-3-4) 

Class  : — Diarthrosis.     Subdivision : — Enarthrodia. 
Capsular  ligament. 
Gleno  humeral  bands  of  the  capsule  : — 

Inner.     Inferior.     Superior,  or  gleno-humeral  ligament. 
Coraco-humeral  ligament. 
Glenoid  ligament.     Biceps  tendon. 
Articular  cartilage. 
Synovial  membrane. 
Transverse  humeral  ligament. 
Muscles — in  relation — with  the  capsular  ligament. 
Arterial  supply.     Nerve-supply. 
Movements. 

The  elbow  joint,  239-40-1.     (244-5-6-7) 

Class : — Diarthrosis.     Subdivision  : — Ginglymus. 
Capsule : — 

Anterior  portion. 

Posterior  portion. 

Internal  portion. 

External  portion. 
Synovial  membrane. 
Arterial  supply. 
Nerve-supply. 
Movements. 

The  radio-carpal  articulation,  245-6-7—8-9.     (251-2-3-4) 

Class  : — Diarthrosis.     Subdivision  : — Ginglymus. 
Anterior  radio-carpal. 
Posterior  radio-carpal  ligament. 
Internal  lateral  ligament. 
External  lateral  ligament. 
Synovial  membrane. 
Arterial  supply.  , 

Nerve-supply. 
Movements. 

The  union  of  the  radius  with  the  ulna,  241-2-3-4-5.     (247-8-9-50) 
Superior  radio-ulnar. 

The  union  of  the  shafts, — the  mid  radio-ulnar  union. 
Inferior  radio-ulnar. 
The  superior  radio-ulnar  joint. 

Class  : — Diarthrosis.     Subdivision : —  Trochoides. 
Orbicular  ligament. 
Synovial  membrane. 
Arterial  and  nerve-supply. 

The  mid  radio-ulnar  union. 

Oblique  ligament. 

Interosseous  membrane.     Inferior  oblique  ligament.     Oblique  ligament. 


THE    UPPER   EXTREMITY.  75 

The  inferior  radio-ulnar  joint. 

Class: — Diarthrosis.     Subdivision: — Lateral  Ginglymus. 
Anterior  radio-ulnar  ligament. 

Posterior  radio-ulnar  ligament.     Interosseous  membrane. 
Triangular  fibro-cartilage. 
Synovial  membrane. 
Arterial  supply. 
Nerve-supply. 

The  movements  of  the  radius. 
The  carpal  joints,  249-50-1-2-3.     (254-5-6-7-8) 

Joints  of  the  first  row. 

Joints  of  the  second  row. 

Medio-carpal. 
The  union  of  the  first  row  of  carpal  bones. 

Class  : — Diarthrosis.     Subdivision  : — Arthrodia. 
Two  dorsal  ligaments. 
Two  palmar  ligaments. 
Two  interosseous  fibre-cartilages. 
Synovial  membrane. 

The  union  of  the  pisiform  bone  with  the  rest  of  the  first  row. 

Capsule. 
The  union  of  the  second  row  of  carpal  bones. 

Class  : — Diarthrosis.     Subdivision  : — Arthrodia. 
Three  dorsal  ligaments. 
Three  palmar  ligaments. 
Two  interosseous  ligaments. 
Synovial  membrane. 

The  medio-carpal  joint,  or  the  union  of  the  two  rows  of  the  carpus  with  one 
another. 

Ligaments: — Anterior  or  palmar  medio-carpal. 

Posterior,  or  dorsal  medio-carpal  ligament. 

Transverse  dorsal  ligament. 
Synovial  membrane. 
Arterial  supply. 
Nerve-supply. 
Movements. 

The  carpo-metacarpal  joints,  253-4-5.     (258-9) 

Carpo-metacarpal  joints  of  the  four  inner  fingers. 
Carpo-metacarpal  joint  of  the  thumb. 
The  four  inner  carpo-metacarpal  joints. 

Class : — Diarthrosis.     Subdivision : — Arthrodia. 
The  dorsal  ligaments. 
The  palmar  ligaments. 
Interosseous  ligament. 
Synovial  membrane. 
Arteries. 
Nerves. 
Movements. 

The  carpo-metacarpal  joint  of  the  thumb. 

Class  : — Diarthrosis.     Subdivision  : — Arthrodia. 
Capsular  ligament. 
Synovial  membrane. 
Arteries. 
Nerves. 
Movements. 

The  intermetacarpal  articulations,  255.     (260) 

Class :  — Diarthrosis.     Subdivision : — Arthrodia. 
Dorsal  ligaments. 
Palmar  ligaments. 
Interosseous  ligaments. 
Arteries. 
Nerves. 
Synovial  membrane. 


76  OUTLINES  OF  ANATOMY. 

The  union  of  the  heads  of  the  metacarpal  bones. 
Transverse  ligament. 

The  metacarpo-phalangeal  joints,  256-7-8.    (260-1-2) 

The  metacarpo-phalangeal  joints  of  the  four  inner  fingers. 

Class : — Diarthrosis.     Subdivision  : — Ginglymus. 
Glenoid  ligament. 
Lateral  ligaments. 
Posteriorly. 
Synovial  sac. 
Arteries. 
Nerves. 
Movements. 

The  metacarpo-phalangeal  joint  of  the  thumb. 

Class  : — Diarthrosis.     Subdivision  : — Ginglymus. 
Lateral  ligaments. 
Posterior  ligament. 
Sesamoid  bones. 
Arteries  and  nerves. 
Movements. 

The  interphalangeal  articulations,  258.    (262-3) 

Class: — Diarthrosis.     Subdivision  : — Ginglymus. 
Glenoid  ligament. 
Lateral  ligaments. 
Posteriorly. 
Synovial  membrane. 
Arteries  and  nerves. 
Movements. 

THE  THORAX  AND  THORACIC  VISCERA. 

The  surface  of  the  thorax  should  now  be  cleaned  of  all  muscle  tissues,  exposing  the  ribs  and  external 
intercostal  muscles. 

The  thorax,  or  trunk  of  the  body,  935-6.     (914-15) 
Formed  : — In  front. 
Behind. 
Laterally. 
Superior  aperture  : — 

Bounded  : — In  front. 
Behind. 
On  each  side. 

Structures  passing  through  the  upper  aperture  of  the  thorax,  1136.  (1112-13) 
In  the  middle  line. 
On  each  side. 
Lower  opening,  or  base. 

The  structures  of  the  thoracic  wall  should  now  be  exposed  in  place,  in  the   order  and  by  the  methods 
indicated. 

Intercostal  muscles,  417.     (414) 

External  intercostals,  417-18-19,    (414) 

Origin.     Insertion.    Structure.     Nerve-supply.     Relations. 
External  intercostal  fascia. 

Divide  the  external  intercostal  muscles  and  the  external  intercostal  fascia  near  the  lower  border  of 
each  intercostal  space.  Reflect  the  external  intercostal  muscles  upward  and  expose  the  internal 
intercostal  muscles  and  the  intercostal  nerves  and  vessels. 

Internal  intercostals,  419—20—1.     (416—17) 

Origin.     Insertion.     Structure.     Nerve-supply.     Relations. 

Internal  intercostal  fascia. 

The  action  of  the  intercostal  muscles. 

Expose  and  trace  two  or  three  of  the  intercostal  nerves,  as  the  second,  sixth,  and  tenth.     Exercise  care 
not  to  injure  the  pleura. 


THE    THORAX  AND    THORACIC   VISCERA.  77 

Intercostal  nerves,  843-5.     (823~5-6) 
Upper  group.     Lower  group. 
First  thoracic  nerve. 
Upper  intercostal  nerves. 

Lateral  cutaneous  nerves  of  the  thorax. 

Anterior  cutaneous  nerves  of  the  thorax. 
Lower  intercostal  nerves. 

Branches. 

Expose  and  trace  the  intercostal  arteries  in  two  or  three  of  the  intercostal  spaces,  as  the  third,  fifth,  and 
seventh.  In  the  anterior  portion  of  the  upper  intercostal  spaces,  expose  the  internal  mammary  and 
anterior  intercostal  arteries. 

Superior  intercostal  artery,  550.     (540-1) 

Aortic  intercostal  arteries,  subcostal  artery,  581-2.     (570-1) 

The  intercostal  portion. 

Collateral  intercostal  branch. 
Internal  mammary  artery,  548—9-50.     (538—9—40) 

Thoracic  portion  : — 

Anterior  intercostal  arteries. 
Perforating,  or  anterior  perforating  branches. 
Intercostal  veins,  subcostal,  644—5. 
Internal  mammary  veins,  640.     (628) 
Intercostal  lymphatics,  696.     (681) 
Internal  mammary,  sternal,  or  anterior  intercostal  glands,  696.     (681) 

Remove  the  intercostal  muscles  from  the  anterior  portion  of  the  upper  five  intercostal  spaces,  exposing 
the  outer  surface  of  the  parietal  pleura.  With  the  finger  carefully  separate  the  pleura  from  the  anterior 
portion  of  the  second,  third,  fourth,  and  fifth  ribs  and  their  costal  cartilages,  on  each  side ;  also  from  the 
intervening  portion  of  the  sternum.  Divide  the  second,  third,  fourth,  and  fifth  ribs  at  the  axillary  line. 
Divide  the  sternum  transversely  below  the  cartilages  of  the  first  ribs,  also  just  above  the  cartilages  of  the 
sixth  ribs.  Beginning  above,  raise  the  sternum  with  its  attached  cartilages  and  ribs,  drawing  it  forward  and 
downward,  carefully  separating  the  pleura  and  internal  mammary  arteries  from  it.  With  a  chain  hook 
retain  it  at  a  right  angle  with  the  thoracic  wall  while  the  triangularis  sterni  is  exposed,  then  remove  it. 

Triangularis  sterni,  421-2;  Fig.  301.     (418—19) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 

Divide  the  pleura  by  a  vertical  incision  about  six  inches  from  the  median  line,  and  by  incisions  parallel 
with  the  second  and  sixth  ribs,  to  within  about  three  inches  of  the  median  line.  The  flap  thus  formed 
can  be  turned  forward,  and  the  reflection  of  the  pleura  can  be  readily  demonstrated,  also  the  interval 
of  non-approximation  of  the  pleural  sacs.  The  visceral  and  parietal  portions  of  the  pleura  should  then 
be  traced  and  the  relations  studied. 

The  pleurae,  958—60.     (936—8—9) 

Visceral  layer,  or  pleura  pulmonalis. 
Parietal  layer,  or  pleura  costalis.    • 
Ligamentum  latum  pulmonalis. 
Right  pleural  sac. 
Inner  surface. 
Outer  surface. 
Viscera  within  the  thoracic  cavity,  936.     (915) 

Heart.     Lungs. 

Mediastinal  space,  936—7—8.     (915—16—17) 
Superior  mediastinum. 
Anterior.     Posterior. 
Middle  mediastinum. 
Superior  mediastinum  : — 
Boundaries  : — In  front. 
Behind. 
On  each  side. 
Above. 
Below. 

Middle  mediastinum. 
Anterior  mediastinum. 
Posterior  mediastinum. 


7 8  OUTLINES  OF  ANATOMY. 

The  lungs,  958-60.     (936-7-8) 

With  the  blowpipe  inserted  in  the  trachea,  inflate  the  lungs  and  note  their  relations  to  the  heart,  thoracic 
walls,  etc. 

Outer  surface. 

Inner  surface. 

Base. 

Apex. 

Two  lobes.     Third  or  middle  lobe. 

The  branches  of  the  internal  mammary  artery  not  already  shown  should  now  be  exposed  and  traced  ; 
then  divide  the  mammary  vessels  and  throw  them  upward. 

Internal  mammary  artery,  548-9-50.     (538-9-40) 
Lateral  infracostal  artery. 
Superior  phrenic  or  comes  nervi  phrenici. 
Mediastinal  or  thymic  branches. 
Pericardiac  branches. 
Sternal  branches. 
Superior  epigastric  artery. 
Musculo-phrenic  artery:  — 
Phrenic. 

Anterior  intercostals. 
Muscular. 

Strip  the  pleura  from  the  superior  mediastinum  and  pericardium,  also  from  the  adjacent  upper  surface 
of  the  diaphragm,  exposing  the  relations  of  the  pericardium  to  the  diaphragm.  Expose  the  mediastinal 
glands.  Trace  the  phrenic  nerves  ;  then  expose  the  pericardium. 

Anterior  mediastinal  or  sternal  glands,  697.     (682) 
Superior  mediastinal  or  cardiac  glands,  697.     (682) 
Phrenic  nerve,  832.     (812-13) 

Right  side. 

Left  side. 

Branches. 
The  pericardium,  962-3.     (941-2) 

Fibrous  layer.     Ductus  arteriosus.     Sterno-pericardial  bands. 

Make  a  transverse  incision  through  the  pericardium,  extending  between  the  roots  of  the  lungs, 
also  a  median  incision  from  the  aorta  to  the  apex  of  the  heart.  Study  the  relations  of  the  peri- 
cardium to  the  heart  and  the  blood-vessels  at  its  base ;  also  the  position  and  relations  of  the  heart. 

Serous  layer : — 

Parietal  portion. 

Visceral  portion. 
Oblique  sinus. 

Vestiginal  fold  of  the  pericardium.     Oblique  vein  of  Marshall. 
Relations. 
On  opening  the  pericardium  the  following  structures  may  be  observed  : — 

Right  and  left  ventricles.     Right  auricle.     Right  auricular  appendix. 

Aorta.     Superior  vena  cava.     Pulmonary  artery.     Left  auricular  appendix. 

Left  ventricle.    Coronary  sinus.    Cardiac  veins.     Oblique  vein  of  Marshall. 

Coronary  arteries. 
Vessels. 

Lymphatics  of  the  pericardium,  697.     (681-2) 
The  heart,  963-4-5.     (942-3) 
Position  : — Base. 
Apex. 

Lower  border. 
Lateral  borders. 
Size  and  weight. 
Anterior  surface. 
Posterior  surface. 
Auriculo-ventricular  groove. 
Interventricular  groove. 


THE    THORAX  AND    THORACIC   VISCERA.  79 

Expose  the  remains  of  the  thymus  gland,  then  clear  it  away.  Demonstrate  the  superficial  cardiac 
plexus  and  trace  the  superior  and  inferior  cervical  cardiac  nerves  of  the  left  side.  Carefully  dissect 
away  the  pericardium,  fat,  connective  tissue  and  fascia  from  the  base  of  the  heart.  Expose  the  supe- 
rior vena  cava  and  its  tributaries,  also  the  arch  of  the  aorta  and  its  branches. 

The  thymus  body  or  gland,  95 5-6-7.     (935-6) 
Relations. 
Structure. 
Vessels : — Arteries. 

Veins. 
Nerves. 

Lymphatics  of  the  thymus,  697.     (682) 
Superficial  cardiac  plexus,  869-70.     (849) 

Superior  cervical  cardiac  nerve,  left  side,  867.     (847) 
Inferior  cervical  cardiac  nerve  of  the  left  side,  819.     (800) 
The  veins,  638.     (626) 
Pulmonary. 
Systemic. 

Veins  of  the  thorax. 

Innominate,  or  brachio-cephalic  veins,  640—1.     (627-8) 
Right  innominate  vein  : — 
Relations  : — In  front. 
Behind. 
Right. 
Left. 

Left  innominate  vein  : — 
Relations  : — In  front. 
Behind. 
Below. 
Above. 
Tributaries : — 

Internal  mammary  veins. 
Left  superior  intercostal  vein. 
Mediastinal,  pericardial,  and  thymic  veins. 
Superior  or  descending  vena  cava,  639.     (627) 
Relations  : — In  front. 
Behind. 
Right  side. 
Left  side. 
Tributaries. 

Chief  variations  in  the  superior  vena  cava  and  innominate  veins,  642.  (628-9-30) 
(z)   Variations  due  to  the  persistence  of  the  left  duct  of  Cuvier. 
(2)   Variations  due  to  persistence  of  the  left  and  suppression  of  the  right  duct 

of  Cuvier. 

The  aorta,  495  to  501.     (487  to  494) 
Arch  of  the  aorta.     Thoracic  aorta. 
Arch  of  the  aorta  : —  ' 

Ascending  portion  of  the  arch  : — 
Relations: — In  front. 
Behind. 
Right  side. 
Left  side. 

Transverse  portion  of  the  arch  : — 
Relations  : — In  front. 
Behind. 
Above. 
Below. 

Descending  portion  of  the  arch  : — 
Relations: — In  front. 
Behind. 


8o  OUTLINES  OF  ANATOMY. 

Descending  Portion  of  the  Arch — Relations: — 
Right  side. 
Left  side. 
Variations  in  the  arch  of  the  aorta  : — 

Variations  in  the  aortic  arch  itself : — 

(a)    Variations  depending  on  abnormalities  in  development  of  the  ventral 

aortic  stem. 
(]))    Variations  depending  on  abnormalities  in  development  of  the  fourth 

and  fifth  aortic  or  branchial  arches. 
(V)    Variations  depending  on  abnormalities  in  development  of  the  dorsal 

aortic  stems. 

Branches  of  the  arch  of  the  aorta  : — 
Ascending  portion. 
Transverse  portion. 
Descending  portion. 
Transverse  portion,  II,  503.     (495) 
Innominate. 
Left  common  carotid. 
Left  subclavian  artery. 

Innominate,  or  brachio-cephalic  artery,  503-4.     (495-6) 
Relations  : — In  front. 
Behind. 
Right  side. 
Left  side. 

Variations  in  the  innominate  artery. 

Branches  of  the  innominate  artery  :  — 

(1)  Right  common  carotid. 

(2)  Right  subclavian. 

Thoracic  portion  of  the  left  common  carotid,  505-6.     (497) 
Relations  : — In  front. 

Behind. 

Right  side. 

Left  side. 

Left  subclavian  artery,  536-7.     (527-8) 
Relations  : — In  front. 

Behind. 

Right  side. 

Left  side. 

The  chief  variations  in  the  three  primary  branches  of  the  transverse  por- 
tions of  the  aortic  arch,  501.     (493) 

(7),  (2},   (J),  (*),  (J),  (6\     ' 

Strip  the  pleura  from  the  anterior  and  posterior  surfaces  of  the  root  of  the  lung.  Trace  the  pulmonary 
artery  and  its  divisions  to  the  lung,  and  the  pulmonary  veins  from  the  lung  to  the  left  auricle.  Dissect 
out  the  areolar  tissue,  glands,  etc.,  and  expose  and  separate  the  component  parts  of  the  root  of  the 
lung.  Special  care  should  be  exercised  not  to  injure  the  nerve  plexuses  and  the  branches  to  and  from 
them.  The  anterior  pulmonary  plexus  consists  of  a  few  small  fibres  in  front  of  the  root  of  the  lung  ;  the 
posterior  plexus  is  larger  and  readily  exposed.  The  pneumogastric  nerves  should  be  exposed  on  each 
side  and  traced  to  the  posterior  plexus.  To  expose  the  pneumogastric  nerve  and  the  posterior  plexus  on 
each  side,  draw  the  lung  forward  and  over  to  the  opposite  side  and  retain  it  in  place  with  hooks  while 
exposing  the  structures  behind  the  root. 

Anterior  pulmonary  branches  (plexus),  819.     (800) 
Pulmonary  artery,  conus  arteriosus,  491-2-3-5.     (483-4-5-7) 
Trunk  of  the  pulmonary  artery  : — 

Ductus  arteriosus,  or  ductus  Botalli. 
Relations  : — In  front. 
Behind. 
Right. 
Left. 


THE    THORAX  AND    THORACIC   VISCERA.  81 

Right  pulmonary  artery  : — 

Relations  : — In  its  course  to  the  lung  :  — 
In  front. 
Behind. 
Above. 
Below. 

At  the  root  of  the  lung  : — 
Above  and  behind. 
Below  and  in  front. 
Left  pulmonary  artery  :  — 

Relations  at  the  root  of  the  lung  : — 
Behind  and  below. 
Below  and  in  front. 
Pulmonary  veins,  639.     (626-7) 
Root  of  the  lung,  960-1.     (939-40) 

Pulmonary  artery,  pulmonary  vein,  bronchial  tube,  bronchial  vessels, 
anterior  and  posterior  pulmonary  plexuses,  lymphatic  glands,  areolar 
tissue — all  encased  in  a  pleural  covering. 
Right  root. 
Left  root. 

Arrangement  of  structures  within  the  root : — 
From  above  downward  : — 
Right  side. 
Left  side. 

From  before  backward. 
Right  vagus  nerve,  817.     (798) 
Left  vagus  nerve,  817.     (798) 

Inferior  or  recurrent  laryngeal  nerve,  818-19.     (799-800) 
Of  the  right  side. 
Left  side. 
Posterior  pulmonary  plexus,  819.     (800) 

Divide  the  superior  vena  cava  just  below  the  termination  of  the  vena  azygos  major  (642;  Fig.  382). 
Divide  the  right  pulmonary  artery  near  the  right  lung;  draw  the  arch  of  the  aorta  and  the  base  of  the 
heart  forward  and  to  the  left  and  expose  the  deep  cardiac  plexus,  tracing  the  branches  to  and  from  it. 
The  thoracic  portion  of  the  trachea  and  the  bronchial  tubes  will  also  be  exposed. 

Cardiac  plexus,  869-70.     (849-50) 

Deep  cardiac  plexus. 
Cardiac  branches — of  the  pneumogastric  and  sympathetic  nerves,  819,  867.   (800,  847) 

Superior  cervical  cardiac  nerve. 

Middle  cardiac  nerve. 

Inferior  cervical  cardiac  nerve,  right. 

Thoracic  cardiac  branches. 
Right  coronary  plexus,  870.     (850) 
Left  coronary  plexus,  870.     (850) 
Trachea  or  air  tube,  950-1.     (929) 

Thoracic  portion. 
The  bronchi,    952.     (931) 

Right  bronchus  : — 
Relations. 

Left  bronchus : — 

Relations. 

Bronchial  glands,  broncho-mediastinal  trunk,  697-8.     (682) 
Expose  the  oesophagus  and  trace  the  pneumogastric  nerves  to  the  diaphragm. 

(Esophagus,  987-8.     (966-7) 
In  the  thorax: — 

Relations : — In  front. 
Behind. 
Laterally. 


82  OUTLINES  OF  ANATOMY. 

Lymphatics  of  the  thoracic  portion  of  the  oesophagus,  697.     (682) 
Right  vagus  nerve,  817.     (798) 
Left  vagus  nerve,  817.     (798) 

Expose  the  thoracic  aorta  and  trace  the  visceral  branches. 

Thoracic  aorta,  579-81.     (568-70) 
Relations  : — In  front. 
Behind. 
Right  side. 
Left  side. 

Branches  of  the  thoracic  aorta  : — 
Visceral.     Parietal. 
Visceral  branches : — 
Pericardial. 
Bronchial  arteries: — 
Right  bronchial. 
Upper  left  bronchial. 
Lower  left  bronchial. 

Branches  to  the  bronchial  glands  and  oesophagus. 
GEsophageal  arteries. 
Bronchial  veins,  645.     (633) 
GEsophageal  veins,  645.     (633) 
Posterior  mediastinal  glands,  697.     (682) 
Thoracic  duct,  698-9.     (683-4) 

Thoracic  portion  of  the  thoracic  duct. 

Relations  : — In  posterior  mediastinum. 

Superior  mediastinum. 
Cervical  portion  of  the  thoracic  duct. 

The  chief  variations  in  the  thoracic  duct. 

Thoracic  portion  of  the  gangliated  cord,  868.     (848) 
Branches : — 

External  branches. 

Internal  branches  of  the  upper  ganglia. 
Internal  branches  of  the  lower  ganglia. 
Internal  branches — upper  series. 
Internal  branches — lower  series. 
Great  splanchnic  nerve. 
Lesser  splanchnic  nerve. 
Smallest  splanchnic  nerve. 
Azygos  veins,  642-4.     (630-1-2) 
Vena  azygos  major  : — 

In  the  posterior  mediastinum  :  — 
Relations : — Left  side. 
In  front. 
Right  side. 

As  it  curls  over  the  root  of  the  lung. 
Tributaries. 
Vena  azygos  minor,  etc.  : — 

Tributaries. 
Vena  azygos  tertia  : — 

Tributaries. 

The  intercostal  veins,  644-5.     (632-3) 
On  the  right  side : — 

Lower  right  superior  intercostal  vein. 
Left  side : — 

Upper  left  superior  intercostal  vein. 
Lower  left  superior  intercostal  vein. 
Aortic  intercostal  arteries,  581-2.     (570-1) 


THE    THORAX  AND    THORACIC   VISCERA.  83 

Vertebral  portion  : — 
Right  side. 
Left  side. 
Intercostal  portion : — 

Pleural  branches,  (572). 
Diaphragmatic  branches,  583.     (573) 
Aberrans  artery,  583-4.     (573) 
Intercostal  nerves,  843-5.     (825-6) 
Upper  intercostal  nerves. 
Lower  intercostal  nerves. 

Intercostal  or  posterior  intercostal  lymphatic  glands,  696.    (68 1) 
Infracostales,  or  subcostals,  422—3.     (419) 

Origin.     Insertion.     Structure.     Xerve-supply.     Action.     Relations.    Endotho- 
racic  fascia. 

Open  the  cavities  of  the  heart  in  the  order  and  by  the  methods  indicated,  exposing  the  structures  with- 
in. The  student  should  at  the  same  time  dissect  the  heart  of  an  ox  or  the  heart  of  a  sheep,  and  de- 
monstrate the  action  of  the  valves  in  the  manner  indicated. 

The  heart  :— 

Four  cavities,  965-6.     (942—3) 
Venous  side. 
Arterial  side. 
The  right  auricle,  966-7—8.     (943-4-5) 

Make  an  incision  through  the  auricular  wall  between  the  superior  and  inferior  venae  cavae, 
and  from  the  middle  of  this  incision  to  the  end  of  the  appendix,  exposing  the  interior  of  the 
auricle. 

Endocardium. 

Sinus  venosus,  or  atrium.     Auricular  appendix. 

Openings : — 

Superior  vena  cava. 

Inferior  vena  cava. 

Auriculo-ventricular  opening. 

Coronary  sinus. 

Foramina  Thebesii. 
Superior  caval  opening. 
Inferior  caval  opening.     Eustachian  valve. 
Coronary  sinus.     Valve  of  Thebesius. 
The  foramina  Thebesii,  vena  Galeni. 
Cavity  of  the  right  auricle. 
Fossa  ovalis.     Annulus  ovalis. 
Tubercle  of  Lower. 

Introduce  the  end  of  the  blowpipe  into  the  right  ventricle  by  passing  it  through  the  pulmonary 
artery  and  between  the  pulmonary  semilunar  valves.  Place  a  ligature  around  the  commence- 
ment of  the  pulmonary  artery,  then  inflate  the  ventricle.  The  action  of  the  tricuspid  valve 
and  the  closing  of  the  auriculo-ventricular  opening  can  be  readily  demonstrated. 

Open  the  right  ventricle  by  two  incisions  as  follows  :  Make  a  vertical  incision  through  the 
ventricular  wall,  about  a  quarter  of  an  inch  to  the  right  of  the  anterior  interventricular  groove 
and  parallel  with  it,  beginning  above  at  the  conus  arteriosus  and  passing  downward  and 
around  the  end  of  the  ventricle ;  make  a  transverse  incision  through  the  upper  part  of  the 
ventricular  wall,  extending  from  the  upper  end  of  the  first  incision  to  the  right  border  of  the 
ventricle,  half  an  inch  below  and  parallel  with  the  auriculo-ventricular  groove.  Exercise 
care  to  divide  the  ventricular  wall  only,  and  not  to  injure  the  structures  within. 

Right  ventricle,  968-9.     (945-6-7) 
Form.     Conus  arteriosus. 
Inner  surface,  or  body  ;  ridges,  bands,  columns  : — 

Columnae  cerneae  ;  musculi  papillares,  moderator  band. 
Musculi  papillares : — 
Anterior. 
Right. 
Posterior. 


84  OUTLINES  OF  ANATOMY. 

Auriculo-ventricular  opening.     Tricuspid  valve,  970.     (948-9) 

Cut  away  the  upper  portion  of  the  conus  arteriosus  enough  to  expose  the  ventricular  surface  of 
the  semilunar  valves,  at  the  commencement  of  the  pulmonary  artery.  Insert  the  blowpipe  in  the 
end  of  the  pulmonary  artery,  retaining  it  in  place  with  a  ligature.  Innate  the  artery  and  demon- 
strate the  action  of  the  valves. 

Open  the  pulmonary  artery  by  a  longitudinal  incision  and  expose  the  pulmonary  semilunar  valves. 

Orifice  of  the  pulmonary  artery,  969.     (937-8) 
Pulmonary  semilunar  valves  :  — 
Sinuses  of  Valsalva. 
Corpus  Arantii. 
Lunulse. 

Open  the  left  auricle  by  an  incision  through  the  auricular  wall,  extending  from  the  right  to  the 
left  pulmonary  vein  (upper),  and  a  second  incision  from  the  middle  of  the  first  incision  to  the  tip 
of  the  appendix. 

Left  auricle.     Cavity,  970-1.     (949-50) 
Openings  : — Pulmonary  veins. 

Auriculo-ventricular  opening. 
Foramina  Thebesii. 

Pass  the  blowpipe  through  the  aorta  into  the  left  ventricle,  in  the  same  manner  as  on  the  right  side, 
and  demonstrate  the  action  of  the  bicuspid  valve  and  the  closing  of  the  auriculo-ventricular 
opening. 

Open  the  left  ventricle  by  an  incision  through  the  ventricular  wall,  about  a  half  an  inch  to  the  left 
of  the  interventricular  grooves,  beginning  below  the  auriculo-ventricular  groove  and  passing 
downward  to  the  apex  of  the  ventricle  and  upward  along  the  opposite  margin  of  the  cavity. 

Left  ventricle,  971.     (950) 

Columnar  carneae. 

Musculi  papillares. 

Chordae  tendinese. 
Auriculo-ventricular  opening,  972.     (950) 

Bicuspid  valve. 

Os  cordis. 
Demonstrate  the  action  of  the  aortic  semilunar  valves  by  inflating  the  aorta. 

Orifice  of  the  aorta,  971-2.     (950) 
Semilunar  valves. 

Open  the  aorta  by  a  longitudinal  incision  and  expose  the  aortic  semilunar  valves.  Trace  the 
vessels  of  the  heart,  laying  them  open  with  the  point  of  the  knife. 

Coronary  arteries,  502-3,  972-3.     (494~5>  951-2) 
Right  coronary  artery  :  — 
Right  auricular  branch. 
Preventricular  branch. 
Right  marginal  branch. 
Posterior  interventricular  branch. 
Transverse  branch. 
Left  coronary  artery  : — 
Left  auricular  branch. 
Large  anterior  interventricular  branch. 
Left  marginal  branch. 
Terminal  branch. 

Variations  in  the  Coronary  Arteries. 

Cardiac  or  coronary  veins,  646-7-8,  973-4-5.     (633-4-5.952-3-5) 
Coronary  sinus: — 

Great  coronary  or  cardiac  vein  :  — 
Anterior  interventricular  vein. 
Left  auricular  vein. 
Left  marginal  vein.' 

Posterior,  middle  cardiac,  or  posterior  interventricular  vein. 
Right  auricular,  right  coronary,  or  small  coronary  vein. 


THE    THORAX  AND    THORACIC   VISCERA.  85 

Coronary  Sinus : — 

Right  marginal  vein,  or  anterior  cardiac  vein,  or  vein  of  Galen. 

Smaller  anterior  cardiac  veins. 
Oblique  vein. 
Cardiac  nerves,  975-6.     (953-5) 

Deep  cardiac  plexus. 

Superficial  cardiac  plexus.     Cardiac  ganglion  of  Wrisberg. 

Coronary  plexuses. 

Lymphatics  of  the  heart,  697.     (682) 
Peculiarities  of  the  Foetal  Heart,  977-8.     (955-6-7) 

Position. 

Weight. 

Auricular  portion.     Right  auricle. 

Ventricular  walls. 

Foramen  ovale.     Valve  of  the  foramen  ovale. 

Eustachian  valve. 

Ductus  arteriosus. 

The  fcetal  circulation. 
The  position  of  the  Chief  Orifices  one  to  the  other  and  to  the  Chest  Wall,  972. 

Fig-  554-     (950-1) 

Pulmonary  orifice.     Aortic  orifice. 
Pulmonary  semilunar  valves. 
Aortic  semilunar  valves. 
Tricuspid  valve. 
Mitral  valve. 
Muscular  walls. 

Study  the  structure  of  the  trachea,  bronchi,  and  lungs,  and  the  arrangement  of  the  vessels  and  air  tubes 
in  the  lungs.     Trace  the  pulmonary  artery  and  its  divisions,  and  the  pulmonary  vein  and  its  tributaries. 

The  trachea:  — 

Structure,  951—2.     (930—1) 

Cartilaginous  rings.     Fibrous  membrane. 

First  cartilage. 

Last  cartilage. 

Fibres  of  the  trachealis. 

Yellow  elastic  fibres. 

Mucous  membrane. 

Arteries. 

Veins. 

Nerves. 

The  bronchi,  952.     (931) 

Right  bronchus.     ,,         ,  .  , 

Bronchioles. 
Left  bronchus. 

The  lungs,  961-2.     (940) 
Weight  of  the  lungs. 
Color. 
Structure: — 

Serous  coat. 
Subserous  layer. 
Parenchyma : — 

Minute  lobules: — 

Bronchial  tube  with  terminal  air  cells. 
Pulmonary  and  bronchial  vessels,  nerves,  and  lymphatics. 
The  vessels : — 

Pulmonary  arteries. 

Radicles  of  the  pulmonary  veins.     Arterial  blood. 
Bronchial  arteries. 
Bronchial  veins : — 
Superficial. 


86  OUTLINES  OF  ANATOMY. 

The  Lungs— The  Vessels:— 

Bronchial  veins — Deep  set. 
Lymphatics. 
Nerves. 
The  oesophagus  : — 

Structure,  988.     (967) 

Muscular,  submucous,  and  mucous  coats. 
Muscular  coat  :  — 

Longitudinal  fibres. 
Circular  fibres. 
Submucous  coat. 
Mucous  coat. 

The  Articulations  at  the  Front  of  the  Thorax,  222-3-4-5. 

The  Chondro-sternal  Articulations. 

Class: — Diarthrosis.     Subdivision  : — Ginglymus. 

Anterior  chondro-sternal  ligament. 

Posterior  chondro-sternal  ligament. 

Superior  and  inferior  ligaments. 

Interarticular  ligament. 

Chondro-xiphoid  ligament. 

Synovial  membranes. 

Arterial  supply. 

Nerves.    - 

Movements. 
The  Costo-chondral  Joints. 

Class  : — Synarthrosis. 

The  Union  of  the  Segments  of  the  Sternum  with  one  another. 
The  Interchondral  Articulations. 

Class  : — Diarthrosis.     Subdivision  : — Arthrodia. 

Capsule. 

Arteries.     Nerves. 

Movements. 

The  Articulations  of  the  Ribs  with  the  Vertebrae,  218-19-20-1-2.     (225-7- 
8-9) 

The  Costo- central  Articulation. 

Class  :  — Diarthrosis.     Subdivision  : — Gingfymo- Arthrodia. 
Capsular  ligament. 
Interarticular  ligament. 
Anterior  costo-central  or  stellate  ligament. 
Synovial  membranes. 
Arterial  supply. 
Nerve-supply. 
Movements. 
The  Costo-transverse  Articulation. 

Class  : — Diarthrosis.     Subdivision  : — Arthrodia. 
Capsular  ligament.     Eleventh  and  twelfth  ribs. 
Middle  costo-transverse  or  interosseous  ligament. 

Eleventh  and  twelfth  ribs. 
Posterior  costo-transverse  ligament. 

Eleventh  and  twelfth  ribs. 
Superior  costo-transverse  ligament ;  from  crest. 

First  rib. 

Synovial  membrane. 
Arterial  and  nerve  supplies. 
Movements. 

MOVEMENTS  OF  THE  THORAX  AS  A  WHOLE,  225-6.     (232-3) 


THE    THORAX  AND    THORACIC   VISCERA.  87 

The  Articulations  of  the  Vertebral  Column,  201  to  208.     (209  to  216) 

(a)  Those  between  the  bodies  and  intervertebral  discs  which  form  amphiarthro- 

dial  joints. 

(£)  Those  between  the  articular  processes  which  form  arthrodial  joints. 
Immediate  :  — 

(a)  Those  between  the  bodies  and  discs. 

(l>)  Those  between  the  articular  processes. 
Intermediate  : — 

(c)  Those  between  the  laminae. 

(</)  Those  between  the  spinous  processes. 

(i)  Those  between  the  transverse  processes. 
The  Articulations  of  the  Bodies  of  the  Vertebrae. 
Class  : — Amphiarthrosis. 

Intervertebral  substances  : — 
Laminar  portion. 
Central  portion. 

Anterior  common  ligament. 

Posterior  common  ligament. 

Lateral  or  short  vertebral  ligaments. 
The  Ligaments  connecting  the  Articular  Processes. 

Class :  — Diarthrosis.     Subdivision :  — Ar&rodia. 

Capsular  ligaments. 

Synovial  membrane. 
The  ligaments  uniting  the  Laminae. 

Ligamenta  subflava. 

The  Ligaments  connecting  the  Spinous  Processes  with  one  another. 
The  ligaments  connecting  the  Transverse  Processes  with  one  another. 

Supraspinous  ligament. 

Interspinous  ligaments. 

Intertransverse  ligaments. 
Arterial  supply. 
Nerve-supply. 
Movements. 

Neck. 

Thoracic  region. 

Lumbar  region. 

The  Male  Perinaeum. 

To  expose  the  perinseum  for  dissection,  draw  the  subject  to  the  end  of  the  table,  flex  the  thigh  and  leg, 
and  bind  the  palm  of  the  hand  over  the  dorsal  surface  of  the  foot.     A  slender  stick  placed  between  the 
knees  will  keep  the  thighs  separated.     The  pelvis  should  be  raised  on  a  block. 
THE  PERINVEUM,  1150-1156.     (1126-1132) 

Bony  boundaries. 

Two  triangles: — (i)  Anterior  or  urethral. 

(2)  Posterior  or  rectal. 

Central  point  of  the  perinaeum,  lateral  lithotomy. 
The  urethra. 
Ischio-rectal  fossa. 

Anterior  recess,  posterior  recess. 
Anus.     Rectum. 
Dissection  of  the  perinaeum. 

The  rectum  should  be  moderately  distended  with  tow  and  the  margins  of  the  anus  stitched  together. 
A  full-sized  staff  should  be  passed  into  the  bladder  and  tied  in  place.  The  scrotum  should  be  stitched 
forward  out  of  the  way. 

The  perinaeum.     The  outlet  of  the  pelvis,  1096.     (1072-3) 
The  male  perinaeum,  1096.     (1073—4) 

The  ischio-rectal  region,  1097.     (1074) 

Beginning  at  the  base  of  the  scrotum,  make  an  incision  along  the  median  raphe,  around  the  margin  of 
the  anus  and  back  to  the  end  of  the  sacrum.  Make  a  transverse  incision  passing  just  in  front  of  the 
tuberosities  of  the  ischium.  Carefully  reflect  the  skin  and  expose  the  superficial  fascia. 


88  OUTLINES  OF  ANATOMY. 

In  the  urethral  triangle  the  superficial  fascia  consists  of  two  well-marked  layers,  a  superficial  layer  and 
a  deeper  layer,  or  fascia  of  Colles.  The  deep  layer,  or  fascia  of  Colles,  turns  around  the  posterior 
border  of  the  superficial  transverse  perinsei  muscles,  and  blends  with  the  posterior  border  of  the  tri- 
angular ligament,  not  extending  over  the  rectal  triangle.  The  superficial  layer  of  the  fascia  should 
now  be  removed,  carefully  preserving  the  deeper  layer,  or  fascia  of  Colles.  In  the  rectal  triangle  the 
external  sphincter  ani  and  the  superficial  vessels  and  nerves  will  be  exposed. 

Sphincter  ani  externus,  action,  1097-8.     (1074) 

Dissect  out  the  fat  from  the  ischio-rectal  fossae,  and  expose  the  hsemorrhoidal  vessels  and  nerves.  The 
greatest  care  should  be  exercised  not  to  injure  the  fascial  boundaries  of  the  ischio-rectal  fossae. 

Ischio-rectal  fossae,  contents,  1102-3.     (IO97) 

The  obturator  fascia,  1098-9;  Fig.  648.     (1075) 
Lower  or  ischio-rectal  segment. 

Ischio-rectal  or  anal  fascia,  1102;  Fig.  648.     (1077-9) 
External  or  inferior  haemorrhoidal  branches,  609.     (597) 
Inferior  haemorrhoidal  nerve,  858.     (838) 
Perinaeal  branch — of  the  fourth  sacral  nerve,  853.     (834) 
Superficial  lymphatics  of  the  perinaeum,  700.     (685) 
Perinaeum  proper,  fascia  of  Colles,  1103.     (1080) 

Fascia  of  Colles,  1103-4.     (1080-1) 

Demonstrate  the  attachments  of  the  fascia  of  Colles,  and  the  extent  and  outline  of  the  superficial  peri- 
nasal  interspace.  To  do  this,  make  a  short  incision  through  the  fascia,  a  little  to  one  side  of  the  median 
line;  introduce  the  point  of  the  blowpipe,  and  drive  air  into  the  space;  the  attachments  of  the  fascia 
and  the  outline  of  the  space  will  be  rendered  distinct. 

Divide  the  fascia  of  Colles  and  reflect  it,  exposing  the  structures  in  the  superficial  interspace.  Fig. 
370  A,  P.  609,  and  Fig.  371.  (598) 

Superficial  perinaeal  interspace,  1104-5.     (1081) 
Contents: — (i)  The  crura,  1070.     (1047) 

The  ischio-cavernosus,  1072.     (1049) 
Compressor  venae  dorsalis. 

(2)  The  bulb,  1071-2.     (1049) 

Expose  the  bulbo-cavernosus;  study  its  structure  and  relations,  then  divide 
the  muscle  near  the  median  line  and  reflect  it  from  the  surface  of  the  bulb. 

Bulbo  cavernosi,  1072.     (1049) 

(3)  Superficial  transversi  perinsei,  1072.     (1049-50) 

(4)  Arteries  of  the  corpora  cavernosa. 
Dorsal  arteries  of  the  penis. 
Veins.     Lymphatics. 

Artery  of  the  corpus  cavernosum  (crus),  611.     (599) 
Dorsal  artery  of  the  penis,  611.     (599) 

(5)  Dorsal  nerves  of  the  penis,  858.     (837) 

(6)  Superficial  perinaeal  vessels  and  nerves. 

Superficial  perinaeal  branch,  609-10.     (597-8) 

Transverse  perinaeal  artery. 
Posterior  or  external  superficial  perinaeal  nerve,  858. 

(838) 

Anterior  or  internal  superficial  perinaeal  nerve,  858. 

(838) 

The  long  pudendal  nerve  may  be  traced  to  advantage  at  this  time.     Follow 
the  nerve  back  to  its  superficial  origin  and  trace  the  branches  forward. 

The  long  pudendal  nerve,  857.     (837) 

Remove  the  muscles  from  the  superficial  perinseal  interspace  and  expose  the  inferior  triangular 
ligament. 

Inferior  triangular  ligament,  1105.     (1081-2) 

Divide  and  turn  off  the  inferior  triangular  ligament,  exposing  the  deep  perinseal  interspace.  See  Fig. 
370,  P.  609  (left  side).  (598) 


THE    THORAX  AND    THORACIC   VISCERA.  89 

Deep  perinaeal  interspace,  1105-6.     (1082-3) 

Contents: — (i)  Membranous  urethra,  1074.     (1052) 

(2)  Cowper's  glands. 

(3)  Internal  pudic  arteries. 

Artery  of  the  bulb,  610-11.     (598-9) 

(4)  Pudic  veins. 

(5)  Pudic  lymphatics. 

(6)  Dorsal  nerve  of  the  penis. 

(7)  Transversus  perinaei  profundus,  or  deep  transversus  perinsei  or 
compressor  urethrae. 

Muscular  division  of  pudic  nerve,  858.     (838) 
Superior  or  deep  triangular  ligament,  1106.     (1083) 

Reflect  the  ischio-rectal  fascia  from  the  parietal  surface  of  the  levator  ani  muscle ;  the  muscle  will  be 
considered  again  at  a  later  period  of  the  dissection. 

Levator  ani  muscle,  1099-1100.     (1075) 
Female  External  Genitals  and  Perinaeum. 

To  expose  the  perinaeum  for  dissection,  draw  the  subject  to  the  end  of  the  table,  flex  the  thigh  and  leg, 
and  bind  the  palm  of  the  hand  over  the  dorsal  surface  of  the  foot.  A  slender  stick  placed  between  the 
knees  will  keep  the  thighs  separated.  The  pelvis  should  be  raised  on  a  block. 

Female  external  genitals,  1156-7-8-9.     (1132-4-5)  ;  also,  1076-7.     (1053-4) 
Labia  majora.     Labia  minora  or  nymphae.     Vestibule. 
Vaginal  orifice,  hymen,  carunculae  myrtiformes. 
Fourchette  and  fossa  navicularis. 
Examination  per  vaginam. 
The  perinaeum,  1150-1.     (1126) 
Bony  boundaries. 

Two  triangles: — (i)  Anterior  or  urethral. 
(2)  Posterior  or  rectal. 

The  rectum  and  vagina  should  be  moderately  distended  with  tow,  and  the  orifice  of  each  closed  by 
stitching  together  the  lateral  margins. 

The  perinaeum.     The  outlet  of  the  pelvis,  1096.     (1072-3) 
Perinaeum  proper,  fascia  of  Colles,  1103.     (1080) 
The  female  perinaeum,  1107.     (1083) 

The  ischio-rectal  region,  1097.     (1074) 

Make  elliptical  incisions  around  the  margins  of  the  vagina  and  anus-;  make  a  median  incision  through 
the  intervening  space,  from  the  pubis  to  the  end  of  the  sacrum.  Make  a  transverse  incision  passing 
just  in  front  of  the  tuberosities  of  the  ischium.  Carefully  reflect  the  skin  and  expose  the  superficial 
fascia.  In  the  urethral  triangle  the  superficial  fascia  consists  of  two  layers,  a  superficial  layer  and  a 
deeper  layer,  or  fascia  of  Colles.  The  deeper  layer,  or  fascia  of  Colles,  turns  around  the  posterior  bor- 
der of  the  superficial  transverse  perinaei  muscles,  and  blends  with  the  posterior  border  of  the  triangular 
ligament,  not  extending  over  the  rectal  triangle.  The  superficial  layer  of  the  fascia  should  now  be 
removed,  carefully  preserving  the  deeper  layer,  or  fascia  of  Colles.  In  the  rectal  triangle  the  sphincter 
ani  and  the  superficial  vessels  and  nerves  will  be  exposed. 

Sphincter  ani  externus,  action,  1097-8.     (1074) 

Dissect  out  the   fat  from   the  ischio-rectal  fossae,  and  expose  the  haemorrhoidal   vessels  and  nerves. 

Care  should  be  exercised  not  to  injure  the  fascial  boundaries  of  the  ischio-rectal  fossae. 

Ischio-rectal  fossae,  1102-3.     (I09?) 

Anterior  recess,  posterior  recess. 

Contents. 

The  obturator  fascia,  1098-9;  Fig.  648.     (1075) 
Lower  or  ischio-rectal  segment. 

Ischio-rectal  or  anal  fascia,  1102;  Fig.  648.     (1077—9) 
External  or  inferior  haemorrhoidal  branches,  609.     (597) 
Inferior  haemorrhoidal  nerve,  858.     (838) 
Perinaeal  branch — of  fourth  sacral  nerve,  853.     (834) 
Superficial  lymphatics  of  the  perinaeum,  700.     (685) 
Fascia  of  Colles,  1103-4.     (1080-1) 

Divide   the    fascia   of  Colles  and  reflect  it,  exposing  the  structures  in  the  superficial  perinaeal  inter- 
space, Figs.  654  and  656. 
7 


9o  OUTLINES  OF  ANATOMY. 

Superficial  perinseal  interspace,  1104-5.     (1081) 

Superficial  peringeal  branch,  609-10  ;  Fig.  370  A  (right  side).     (597-8) 

Transverse  peringeal  artery. 

Posterior  or  external  superficial  peringeal  nerve,  858.  (838) 
Anterior  or  internal  superficial  peringeal  nerve,  858.  (838) 
Muscles,  1079  >  also>  II07  >  Figs.  632,  656.  (1056  ;  also,  1084) 

Ischio-cavernosi  (male),  1072.     (1049) 

Bulbo-cavernosi,  constrictor  vaginge. 

Transversi  peringei,  1072.     (1049) 
Peringeal  body,  1107-8.     (1084) 
Vessels,  1077-8.     (1054-5) 

Carefully  raise  and  remove  the  bulbo-cavernosi  and  transversi  perinaei,  and  expose  the  bulbuli 
vestibuli  and  glands  of  Bartholin. 

Bulbuli  vestibuli,  1078-9;  Fig.  632.     (1055-6) 

Pars  intermedialis.     Vessels,  1077-8.     (1054-5) 
Glands  of  Bartholin,  1077.     (1054) 
Clitoris,  glans  clitoridis,  1078.     (1055) 
Inferior  triangular  ligament,  1105.     (1081-2) 
Deep  peringeal  interspace,  1105.     (1082) 
The  urethra,  1079.     (IO56) 

Deep  transversus  peringei,  1107,  1106.     (1084,  1082-3) 
In  the  female: — Artery  of  the  bulb,  6n.     (598-9-600) 
Artery  of  the  crus. 
Dorsal  artery  of  the  clitoris. 
Dorsal  nerve  of  the  clitoris,  858.     (838) 
Superior  or  deep  triangular  ligament,  1106.     (1083) 

Reflect  the  ischio-rectal  fascia  from  the  parietal  surface  of  the  levator  ani  muscle;   the  muscle  will  be 
considered  again  at  a  later  period. 

Levator  ani  muscle,  1099-1100.     (1075) 

THE  ABDOMINAL  WALLS. 

Before  beginning  the  dissection,  study   carefully  the  surface  markings  or  landmarks    of  the   region. 
With  colored  crayons  indicate  on  the  surface  of  the  abdomen  the  position  of  each  structure  mentioned. 

Superficial  Anatomy  of  the  Abdomen,  1141-2-3-4.     (1118-19-21) 
Skin  markings  ;  bones  and  muscular  landmarks  : — 

Linea  alba.     Linea  semilunaris. 

Poupart's  ligament,  external  abdominal  ring. 
Internal  ring.     Canal. 

Vessels  in  the  abdominal  wall. 

Lymphatics. 

Nerves. 

The  diaphragm. 

For  convenience  in  stating  the  position  of  the  enclosed  viscera,  the  abdomen  is  divided  into  nine  regions. 
Outline  the  regions  of  the  abdomen,  and  note  the  contents  of  each  region,  as  indicated  by  the  table. 

THE  ABDOMINAL  VISCERA  REGIONALLY  ARRANGED,  1249.     (1225) 

Right.  Middle.  Left. 

Hypochondriac.  Epigastric.  Hypochondriac. 

Lumbar.  Umbilical.  Lumbar. 

Inguinal.  Hypogastric.  Inguinal. 

Viscera  behind  the  linea  alba,  1145-1150.     (1121-1126) 

(1)  Above  the  umbilicus. 

(2)  Below  the  umbilicus. 
The  liver.     Gall  bladder. 
Stomach.     The  pancreas. 
Intestines : — (A)  Small. 

(B)  Large  intestine. 


THE  ABDOMINAL    WALLS.  91 

Landmarks  for  lumbar  colotomy. 
The  kidneys.     The  spleen. 
Aorta  and  iliac  arteries. 

Some  of  the  branches  of  the  aorta  : — 

Coeliac  axis.     Superior  mesenteric  artery. 
Renal  arteries.     Inferior  mesenteric  artery. 

Dissection  of  the  Abdominal  Walls.  Inguinal  Hernia.  Umbilical  Hernia. 

Make  a  circular  incision  and  raise  a  button  of  skin  around  the  umbilicus.  With  a  narrow  sharp  knife, 
open  into  the  abdominal  cavity  through  the  umbilicus;  through  this  opening  inflate  the  abdominal 
cavity  enough  to  render  the  abdominal  walls  moderately  tense,  close  the  opening  with  a  ligature  tied 
under  the  circular  button.  Make  a  median  incision  from  the  middle  of  the  sternum  to  the  symphysis 
pubis,  and  two  transverse  incisions :  one  from  a  point  midway  between  the  pubis  and  umbilicus,  to  the 
anterior  superior  spine  of  the  ilium  and  along  the  crest,  the  other  from  the  umbilicus  in  the  direction  of 
the  axilla,  to  the  lower  border  of  the  pectoralis  major.  Beginning  at  the  umbilicus  turn  the  skin  upward 
from  that  point,  and  outward  from  the  median  line,  and  expose  the  superficial  fascia  underneath. 

The  Abdominal  Parietes,  425.     (421-2) 

Carefully  turn  off  the  first  layer  of  the  superficial  fascia,  in  the  same  manner  as  the  skin,  and  expose  the 
superficial  vessels  and  nerves. 

The  superficial  nerve  supply  of  the  abdomen  is  derived  from  branches  of  the  lower  intercostal,  ilio-hypo- 
gastric  and  ilio-inguinal  nerves.  Fig.  460,  P.  844.  (824) 

Superficial  nerves: — 

Lower  intercostal  nerves: — 

Lateral  cutaneous  nerves  of  the  abdomen,  845. 
Anterior  branches.     Posterior  branches. 
Anterior  cutaneous  nerves  of  the  abdomen,  846. 
Last  thoracic  nerve,  846.     (826) 

Hypogastric  branch — of  the  ilio-hypogastric,  848.     (829) 
Ilio-inguinal  nerve,  terminal  branches,  849.     (829) 
The  superficial  arteries : — 

From  the  intercostal  arteries: — 

Lateral  cutaneous  branches,  583;  Fig.  362.     (572) 
From  the  femoral :   618.     (606) 

The  portion  of  the  vessels  above  Poupart's  ligament  should  be  exposed  ;  the  origin  from  the 
femoral  will  be  shown  later. 

Superficial  external  pudic. 
Superficial  epigastric. 
Superficial  circumflex  iliac. 

Cutaneous  branches — from  the  deep  circumflex  iliac,  613.     (602) 
Cutaneous  branches — from  the  superior  epigastric,  550.     (540) 
Cutaneous  branches — from  the  deep  epigastric,  613.     (601) 
The  superficial  veins  accompany  the  superficial  arteries. 
Lymphatics  of  the  abdomen  and  pelvis,  699-700 ;  Fig.  400.     (684) 
Parietal  lymphatic  vessels  : — 

Superficial.     Deep. 

Superficial  parietal  lymphatics,  front,  lateral. 
The  inguinal  glands,  705.     (691) 

Oblique  or  inguinal  glands  proper. 

Turn  off  the  deep  layer  of  the  superficial  fascia  and  expose  the  structures  underneath. 

Read  :  The  Muscles,  296-302.     (299—305) 

i.  The  name.     2.  The  shape.     3.  The  attachments ;  origin,  insertion. 
4.   The  structure.     5.  Nerve-supply.     6.   Action. 
The  abdominal  muscles,  linea  alba,  umbilicus,  425-6.     (422) 
Obliquus  externus  abdominis,  428-9-30  ;  Fig.  303.     (424-6—7) 
Origin.     Insertion. 

Structure  :— Triangular  fascia,  Fig.  285;  P.  365.     (364) 
External  abdominal  ring. 
Poupart's  ligament.     Gimbernat's  ligament. 


9  2  OUTLINES   OF  ANATOMY. 

External  abdominal  ring  : — 

Inner  pillar.     External  pillar.     Intercolumnar  fibres. 
Intercolumnar  fascia. 
Nerve-supply.     Action.     Relations.     Variations. 

Carefully  divide  the  aponeurosis  of  the  external  oblique  by  a  transverse  incision,  from  near  the  anterior 
superior  spine  of  the  ilium  to  the  outer  border  of  the  rectus,  then  downward  from  that  point  to  the 
pubis,  passing  to  the  inner  side  of  the  external  abdominal  ring  in  order  to  preserve  it  intact ;  turn  the 
flap  thus  formed  down  and  out  to  Poupart's  ligament.  Also  divide  the  muscle  at  its  origin  and  near  the 
crest  of  the  ilium,  and  turn  forward  to  the  point  where  the  aponeurosis  blends  with  that  of  the  internal 
oblique.  The  ilio-hypogastric — 848 — (829)  and  ilio-inguinal — 849 — (829)  nerves  perforate  the  internal 
oblique  near  the  crest  of  the  ilium  and  cross  the  lower  portion  of  the  muscle. 

Obliquus  internus  abdominis,  431-2.     (427-8).     Fig.  266;  P.  312.     (315) 

Origin.     Insertion,  conjoint  tendon. 

Structure,  linea  semilunaris. 

Nerve-supply.     Action.     Relations.     Variations. 
Cremaster,  432.     (428).     Fig.  285  ;  P.  365.     (364) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Genital  branch — of  the  genito-crural  nerve,  849.     (829) 

Divide  the  internal  oblique  near  its  origin  from  the  crest  of  the  ilium  and  at  Poupart's  ligament,  detach 
from  the  ribs  above,  and  by  a  vertical  incision,  from  the  lumbar  fascia  behind ;  care  must  be  exercised 
to  divide  the  internal  oblique  only.  Near  the  crest  of  the  ilium  the  branches  of  the  deep  circumflex 
iliac  artery  lie  between  the  internal  oblique  and  transversalis,  and  will  indicate  the  depth  of  the  in- 
cision required  to  divide  the  internal  oblique.  Passing  forward  upon  the  transversalis  will  be  seen  por- 
tions of  the  lower  intercostal,  ilio-hypogastric,  and  ilio-inguinal  nerves. 

Nerve's :  — 

Lower  intercostal  nerves  : — Branches,  845.     (826) 

Last  thoracic  nerve,  846.     (826) 

Ilio-hypogastric  nerve,  848.     (829) 

Ilio-inguinal  nerve,  849.     (829) 
Arteries  : — 

From  the  lower  intercostal : — 

The  intercostal  portion,  582.     (571) 
Subcostal  or  twelfth  dorsal,  583.     (572-3) 

Lumbar  arteries,  587-8.     (576-7) 

Deep  circumflex  iliac,  muscular  branches,  613.     (601-2) 
Veins  accompany  the  arteries. 
Lymphatics  : — The  deep  parietal  lymphatics — of  the  anterior  and  lateral  abdominal 

walls,  700.     (685) 
Transversalis  abdominis,  433-4-5  ;  Fig.  304.     (429-30) 

Origin.     Insertion. 

Structure  ;  anterior  aponeurosis,  posterior  aponeurosis  or  lumbar  fascia. 

Nerve-supply.     Action.     Relations. 
Sheath  of  the  rectus,  front  portion  of  sheath,  435.     (430-1) 

Open  the  sheath  of  the  rectus  by  a  vertical  incision  in  the  median  line  of  the  sheath,  reflect  the  outer 
portion  of  the  sheath  to  the  outer  border  of  the  muscle  and  the  inner  portion  toward  the  linea  alba. 
The  pyramidalis  and  rectus  will  be  exposed. 

Pryamidalis,  426.     (422-3)     Fig.  266;  P.  312.     (315) 

Origin.     Insertion.     Structure.     Nerve-supply.   Action.    Relations.  Variations. 
Rectus  abdominis,  426-7-8.     (423-4)     Fig.  266;  P.  312.     (315) 

Origin,  outer  head,  inner  head.     Insertion.     Structure,  lineae  transversae. 

Nerve-supply.     Action.     Linese  transversas.     Relations.     Variations. 

Divide  the  rectus  transversely  near  the  umbilicus,  turn  the  lower  portion  down  to  the  origin  and  the 
upper  portion  to  the  insertion,  expose  the  structures  in  or  under  the  muscles.  In  raising  the  muscle  note 
the  anterior  cutaneous  nerves  entering  its  deep  surface. 

Deep  epigastric  artery,  612-13.     (601) 

Branches: — Cremasteric.     Pubic.     Muscular.     (Cutaneous.)     Terminal. 
Superior  epigastric  artery,  550  ;  Fig.  344.     (540) 

Branches: — Muscular.     Xiphoid  (peritoneal). 


THE   ABDOMINAL    WALLS.  93 

Posterior  portion  of  the  sheath,  435.     (431) 
Fold  of  Douglas.     Transversalis  fascia. 

Divide  the  transversalis  at  its  origin  from  Poupart's  ligament  and  carefully  raise  and  turn  forward  a 
small  portion  of  the  lower  part  of  the  muscle,  exposing  the  transversalis  fascia. 

Transversalis  fascia,  436.     (431-2) 

Deep  crural  arch.     Internal  abdominal  ring.     Infundibuliform  fascia. 

At  the  lower  part  of  the  abdomen,  the  parts  should  now  be  carefully  replaced  and  their  relations  con- 
sidered with  reference  to  the  occurrence  of  inguinal  hernia. 

Parts  Concerned  in  Inguinal  Hernia,  1159  to  1165.     (1135  to  1141) 
External  Ring : 

Formation.     Boundaries.     Shape. 

Intercolumnar  fascia.     External  spermatic  fascia. 

Effect  of  the  Position  of  the  Thigh  on  the  Ring. 
Inguinal  Canal : 

Length.     Direction.     Boundaries. 
Internal  Ring: 

Site.     Shape.     Dimensions.     Boundaries. 
Forms  of  inguinal  hernia  : 

(A)  The  Common  Form  :  External,  or  Oblique. 

(B)  Rarer  Form  :   Internal,  or  Direct. 

A.  Oblique,  External  Inguinal  Hernia,  coverings  of : 

(1)  At  the  internal  ring,  or  inlet. 

(2)  In  the  canal. 

(3)  At  the  external  ring,  or  outlet. 

B.  Direct  or  Internal  Inguinal  Hernia,  coverings  of: 

Make  a  median  incision  through  the  abdominal  wall,  from  the  lower  end  of  the  sternum  to  the  umbili- 
cus. Make  a  transverse  incision  just  above  the  umbilicus.  Draw  the  flaps  thus  formed  out  and  up, 
and  stitch  them  in  place.  Raise  the  lower  portion  of  the  abdominal  wall  and  examine  the  inner  sur- 
face in  the  inguinal  region. 

Posterior  aspect — of  inguinal  hernia  : 
Cords  and  fossae. 

Three  cords  : — Urachus. 

Obliterated  hypogastric  arteries. 
Three  fossae  : — Internal,  middle  fossa,  external  fossa. 
Causes  of  Hernia : 

(1)  Hereditary. 

(2)  Weak  Spots. 

(3)  (4)  (5)  (6)  (7)  (8)  (9)  O)  (») 

Parts  Concerned  in  Umbilical  Hernia,  1169-70.     (1145-6) 
Congenital  umbilical  hernia. 
Infantile  umbilical  hernia. 

Prevented  by: — Changes  in  the  Ring  Itself. 

Changes  in  the  Vessels  Themselves. 
Umbilical  hernia  of  adult  life. 
Coverings  of  an  umbilical  hernia. 

Continue  the  division  of  the  abdominal  wall  to  the  pubis,  carrying  the  incision  one-half  an  inch  to  the 
left  of  the  median  line.  Xote  again  the  position  of  the  obliterated  hypogastric  arteries  and  the  urachus. 
The  scrotum  and  spermatic  cord  will  next  be  considered. 

Make  an  incision  from  the  external  ring  to  the  tip  of  the  scrotum,  in  line  with  the  spermatic  cord, 
reflect  the  skin  and  expose  the  dartos.  Demonstrate  the  septum  scroti. 

The  Scrotum,  1060-1.     (1038-9) 
Scrotal  integument,  raphe. 

Superficial  lymphatics  of  the  scrotum,  700.     (685) 
Dartos. 

Septum  scroti. 


94  OUTLINES  OF  ANATOMY. 

On  the  right  side  divide  the  spermatic  cord  at  the  external  ring,  carefully  remove  the  cord  and 
testicle,  with  their  coverings,  and  pin  them  out  in  a  dissecting  tray.  The  coverings  of  the  cord 
and  testicle  can  be  readily  demonstrated  by  dissection  under  water. 

On  the  left  side,  reflect  the  coverings,  and  expose  the  cord  in  place ;  demonstrate  and  trace  its 
constituent  parts.  Follow  the  vas  deferens  from  the  testicle  to  the  brim  of  the  pelvis.  Drop  the 
testicle  in  the  pelvic  cavity,  not  dividing  the  vas  deferens,  and  preserve  it  for  study  later. 

External  spermatic  or  intercolumnar  fascia. 
Cremasteric  or  middle  spermatic  fascia. 
Internal  spermatic  or  infundibuliform  fascia. 
Tunica  vaginalis. 
Vessels  and  nerves  : 

Arteries.     Veins.     Lymphatics. 

Nerves. 

Spermatic  Cord,  1068-9.     (IO45~6) 
Vas  deferens. 
Spermatic  artery : 

Branches: — Epididymal  and  testicular,  596.     (584) 
Spermatic  veins : 

Pampiniform  plexus,  671.     (656-7) 
Lymphatics. 
Sympathetic  nerve. 
Processus  vaginalis. 
Internal  cremaster. 
Fat  and  connective  tissue. 

Cut  away  the  superficial  muscles  of  the  abdominal  wall,  stitch  back  the  flaps  formed  by  the  division  of 
the  walls,  and  examine  the  abdominal  organs. 

The  Abdomen  and  Its  Contents. 

The  Abdomen,  994-5.     (973-4) 

Study  the  location  of  the  organs  in  the  abdominal  cavity  as  indicated  by  the  table  : — 
The  Abdominal  Viscera  Regionally  Arranged,  J2^.g.     (f22j] 

The  general  description  of  each  organ  and  its  relations  to  the  surrounding  parts,  should  now  be  care- 
fully considered,  while  the  organs  are  in  place.      The  structure,  etc.,  will  be  studied  later. 

The  stomach,  996-7-8  ;  Figs.  566-7.     (974-5-6-7) 
Cardiac  orifice. 
Pyloric  orifice,  or  pylorus. 
Borders.     Surfaces. 
Relations  to  surrounding  parts. 
Relations  to  the  peritoneum. 
Alteration  of  position. 
The  small  intestine,  1000.     (978) 

(Duodenum.)     Jejunum.     Ileum. 
Jejunum  and  ileum,  1002-3.     (981-2) 
Jejunum. 

Ileum.     Meckel's  diverticulum. 
The  mesentery. 

The  large  intestine,  1005-6-7.     (983-4-5-6) 
Caecum,  or  caput  coli. 

The  vermiform  appendix. 
Ileo-caecal  fossa. 
The  colon,  1008-9.     (986-7) 
The  ascending  colon. 
The  transverse  colon. 
The  descending  colon. 

The  sigmoid  flexure  and  rectum,  1009-10-11.     (987-8-9) 
The  liver,  1012-13-14-15.     (990-1-2-3) 

Weight.     Borders.     Extremities.     Surfaces.     Lobes.     Fissures.     Ligaments. 
Anterior  border.     (Posterior  border.) 


THE  ABDOMINAL    WALLS.  95 

The  Liver: — 

Right  extremity.     Left  extremity. 
Superior  surface. 
Inferior  surface. 

Longitudinal  fissure. 

Umbilical  fissure. 

Quadrate  lobe. 

Gall  bladder,  1020-1.     (998) 

Fundus.     Neck.     Body. 

General  position,  1016-17-18.     (994-5-6) 
Ligaments  of  the  liver,  1019.     (997) 

Coronary  ligament. 

Right  and  left  lateral  ligament. 

Broad  ligament.     Round  ligament. 
The  spleen,  1025-6-7-8.     (1003-4-5) 
Position.     Shape. 
Surfaces : — 

External  or  posterior  surface. 

Anterior. 

Inner  or  renal  surface. 
Anterior  border.     Posterior  border. 
Size.     Varieties. 
General  relations  of  the  spleen.     (1006) 

The  general  location  of  the  kidney  may  now  be  determined,  its  exact  position  and  relations  will  be  fully- 
considered  later.  The  pancreas  will  also  be  exposed  at  a  later  period  of  the  dissection. 

The  kidneys,  1042-3-4-5.     (1020—1-2—3) 
(Position  and  relations.) 

Carefully  trace  the  peritoneum  and  demonstrate  its  attachments,  reflections,  and  relations  to  the  abdomi- 
nal walls  and  abdominal  organs.  Study  the  plan  of  formation  of  the  amenta,  mesenteries,  and  liga- 
ments. 

The  peritoneum,  989-90-1-2-3-4.     (968-9—70-1-2) 
Greater  and  lesser  sacs  of  the  peritoneum. 
Foramen  of  Winslow. 
Course  of  the  peritoneum  in  a  longitudinal  section  of  the  body. 

Recto-vesical  pouch.     Recto-vaginal  pouch. 

Lesser  sac.     Great  omentum.     Lesser  or  gastro-hepatic  oraentum. 

Gastro-splenic  omentum. 

The  gastro-phrenic  and  phreno-colic  ligaments. 
Fossa  duodeno-jejunalis,  1002.     (981) 

In  connection  with  the  demonstration  of  the  peritoneum,  the  student  should  also  read  the  chapter  on 
The  Evolution  of  the  Peritoneum  and  an  Explanation  of  its  arrangement  in  the  Human  Body. 
Pages  1028-1041.  (7006-70/9) 

The  structures  between  the  layers  of  peritoneum  forming  the  mesentery  and  transverse  meso-colon 
should  now  be  exposed.  To  do  this,  raise  the  great  omentum  and  transverse  colon  and  throw  them  up 
over  the  lower  wall  of  the  chest.  Draw  down  the  mass  of  small  intestines  and  spread  them  out  in  such 
a  manner  as  to  expose  the  anterior  peritoneal  layer  of  the  mesentery.  Beginning  at  the  upper  part  of 
the  jejunum  and  proceeding  downward,  strip  off  the  anterior  layer  of  peritoneum  from  the  mesentery 
of  the  small  intestine,  also  the  peritoneum  covering  the  ascending  colon,  and  the  inferior  layer  of  the 
transverse  mesocolon.  Expose  the  mesenteric  artery  and  trace  its  branches.  The  mesenteric  veins, 
nerves,  the  mesenteric  glands  and  lacteals,  will  also  be  exposed  at  the  same  time. 

Superior  mesenteric  artery,  592-3-4;  Fig.  366.     (581-2-3) 
Branches: — Intestinal  branches,  or  vasa  intestini  tenuis. 
Ileo-colic 
Right  colic. 
Middle  colic. 

Inferior  pancreatico-duodenal. 
Variations  in  the  superior  mesenteric  artery. 

Superior  mesenteric  plexus,  871.     (852) 


96  OUTLINES  OF  ANATOMY. 

Superior  mesenteric  vein,  674-5  ;  Fig.  393.     (661) 

Tributaries  : — Right  gastro-epiploic. 

Pancreatico-duodenal  veins. 
Lymphatic  vessels  of  the  intestines,  703.     (687) 

Lymphatics  of  the  small  intestine,  lacteals. 

Lympathics  of  the  large  intestine,  (a),  (b). 
Lymphatic  glands  of  the  intestines,  703.     (687-8) 

Mesenteric  glands. 

Meso-colic  glands. 

Expose  the  inferior  mesenteric  vessels;  to  do  this,  draw  the  small  intestine  to  the  right,  carefully  strip 
off  the  peritoneum  from  the  lower  portion  of  the  aorta,  and  to  the  left,  beyond  the  descending  colon  and 
sigmoid  flexure. 

Inferior  mesenteric  artery,  596-7;  Fig.  367.     (586-7) 
Branches  of  the  inferior  mesenteric  :  — 
Left  colic. 
Sigmoid  artery. 
(Superior  haemorrhoidal.) 
Chief  variations  in  the  inferior  mesenteric. 

Inferior  mesenteric  plexus,  871.     (852) 

Aortic  plexus,  871.     (852) 

Inferior  mesenteric  vein,  676;  Fig.  394.     (662) 

Lymphatics  of  the  large  intestine,  (c),  703.     (687) 

Remove  the  jejunum  and  ileum  from  the  abdominal  cavity.  First  tie  two  ligatures  around  the  jejunum 
at  its  commencement,  and  divide  the  intestine  between  them;  divide  the  ileum  in  the  same  manner, 
about  four  inches  above  its  termination  in  the  csecum.  Divide  the  mesentery  near  the  intestine.  The 
portion  of  intestine  thus  removed  should  be  washed  out  and  carefully  dissected  to  show  the  structure. 

Structure  of  the  small  intestine,  1003-4-5  ;  Figs.  573-4.     (982-3) 
Blood-supply  of  the  small  intestine. 
Lymphatics  and  nerves. 

Ligature  the  sigmoid  flexure  at  the  brim  of  the  pelvis,  and  divide  the  intestine  at  that  point;  divide  the 
great  omentum  along  the  lower  border  of  the  stomach  below  the  gastro-epiploic  arteries.  Remove  the 
remainder  of  the  ileum  and  the  colon,  wash  them  out,  and  study  the  structure.  The  lower  portion  of 
the  ileum  and  the  first  six  inches  of  the  large  intestine  should  be  inflated  and  allowed  to  dry ;  on  the 
dried  specimen,  remove  the  lateral  wall  of  the  caecum  at  the  point  of  entrance  of  the  ileum  •  the  arrange- 
ment and  structure  of  the  ileo-csecal  valve  will  be  shown. 

Structure  of  the  large  intestine,  1012.     (990) 
Blood-vessels.     Nerves  and  lymphatics. 
The  ileo-caecal  valve,  1007-8.     (986) 

Expose  the  cceliac  axis  and  its  branches;  to  do  this,  raise  the  liver,  draw  down  the  stomach,  and  strip 
off  the  anterior  layer  of  the  gastro-hepatic  omentum.  The  gastric  artery  is  easily  found  as  it  passes 
along  the  lesser  curvature  of  the  stomach,  and  by  tracing  it  to  its  origin  the  cceliac  axis  can  be  readily 
exposed  and  its  divisions  followed. 

Cceliac  artery  or  cceliac  axis,  588-9;  Fig.  365.     (577-8) 
Relations  : — In  front,  behind,  above,  below,  right,  left. 
Variations. 

Branches  of  the  coeliac  artery,  589-90-1-2.     (578-9-80-1) 
Gastric  or  coronary  artery  : — 
(Esophageal  branches. 
Cardiac  branches. 
Gastric  branches. 

Lesser  anterior  and  posterior  gastric  branches. 
Greater  anterior  gastric. 
Hepatic  branch. 

Chief  variations. 

Gastric  or  coronary  vein,  674.     (660-1) 
Hepatic  artery. 


THE   ABDOMINAL    WALLS.  97 

Branches  of  the  hepatic  artery  : — 
Pancreatic  or  lesser  pancreatic. 
Superior  pyloric. 
Gastro-duodenal : — 

Right  gastro-epiploic :  — 

Ascending  or  gastric  branches, 
Epiploic  or  omental  branches. 
Superior  pancreatico-duodenal. 
Inferior  pyloric. 
Right  terminal  branch  : — 

Cystic  artery. 
Left  terminal  branch. 

Chief  variations. 

Draw  the  stomach  forward  and  throw  the  lower  border  upward  on  the  chest  wall ;  retain 
it  in  this  position  while  the  splenic  artery  and  its  branches  are  exposed. 

Splenic  artery. 

Branches  of  the  splenic  artery  : — 
Smaller  pancreatic  branches. 
Larger  pancreatic  branch. 
Left  gastro-epiploic :  — 

Ascending  or  gastric  branches. 
Descending  epiploic  or  omental  branches. 
Vasa  brevia. 
Terminal  branches. 

Variations  in  the  splenic  artery. 

Creliac  plexus,  870-1.     (850) 
Splenic  plexus. 
Hepatic  plexus: — 

Pyloric.     Right  gastro-epiploic. 
Pancreatico-duodenal  plexus. 
Cystic  plexus. 
Coronary  plexus. 
The  Cceliac  glands,  701.     (686) 
Lymphatics  of  the  stomach,  702.     (687) 
Superior  gastric. 
Inferior  gastric  lymphatics. 
Left  gastric  lymphatics. 

Lymphatic  glands  of  the  stomach,  702-3.     (687) 
Superior  gastric  glands. 
Inferior  gastric  or  gastro-epiploic  glands. 
The  splenic  vein,  675-6.     (662) 
Tributaries  : — Vasa  brevia. 

Left  gastro-epiploic. 
Pancreatic. 
Inferior  mesenteric. 
Hepatic  glands,  704.     (688-9) 
Portal  vein,  673-4 ;  Fig.  392.     (659-60) 
Sinus  of  the  portal  vein. 
Right  branch. 
Left  branch. 
Tributaries: — 

Pyloric.     (Gastric.)     Cystic.     (Superior  mesenteric.     Splenic.) 

Draw  down  the  oesophagus  and  apply  a  ligature  just  below  the  diaphragm.  Loosen  the  ligature  at  the 
lower  end  of  the  duodenum,  introduce  the  blowpipe  and  partially  innate  the  duodenum  and  stomach, 
then  withdraw  the  blowpipe  and  renew  the  ligature.  Expose  the  duodenum  and  pancreas  and  study 
their  relations. 


98  OUTLINES  OF  ANATOMY. 

Duodenum,  1000-1-2;  Figs.  570-1.     (978-9-80-1) 

First  part,  the  superior  or  ascending. 

Second  part,  the  descending  portion. 

Third  part,  or  transverse  portion. 

Fourth  part.     Musculus  suspensorius  duodeni. 

Pancreas,  1023-4-5  ;  Fig.  587.     (1001-2) 
Head  of  the  pancreas. 
Body  of  the  pancreas. 
Tail  of  the  pancreas. 

Open  the  gland  by  an  incision  a  little  below  the  median  line,  extending  from  the  head  to  the  tail, 
and  expose  the  duct. 

Duct  of  the  pancreas. 

Blood-supply.     Lymphatics.     Nerves. 
The  common  bile  duct,  ampulla  of  Vater,  1021.     (999) 
Abdominal  branches  of  the  pneumogastric  nerve,  819.     (800) 

Apply  a  ligature  and  divide  the  resophagus  just  below  the  diaphragm.  Remove  the  stomach,  duo- 
denum, pancreas,  and  spleen,  dividing  the  vessels  and  folds  of  peritoneum  which  hold  them  in  place. 
The  arteries  should  be  divided  about  an  inch  from  their  origin.  Divide  the  pancreatic  duct  near  the 
duodenum,  remove  the  gland,  and  examine  its  structure.  Clean  the  surface,  and  wash  out  the  duo- 
denum and  stomach,  and  study  their  structure. 

The  pancreas,  1023-4-5.     (1001-2) 

Lymphatics  of  the  pancreas,  704.     (689) 
The  stomach,  998-9;  Figs.  568-9.     (977-8)- 

Structure. 

Nerves.     Blood-supply.     Lymphatics. 
The  pylorus,  996;  Fig.  566.     (974-5) 
Duodenum-Structure  of  small  intestine,  1003-4.     (982-3) 
The  spleen. 

Structure.     Blood-supply.     Lymphatics.     Nerves,  1028.     (1005-6) 

Lymphatics  of  the  spleen,  704.     (689) 
Splenic  glands. 

Remove  the  liver  and  demonstrate  its  parts  and  structure.  To  remove  the  liver,  cut  the  hepatic  artery 
near  its  origin;  divide  the  suspensory  ligament  from  before  backward,  drawing  the  liver  downward 
and  forward ;  divide  the  lateral  ligaments  and  the  upper  layer  of  the  coronary  ligament,  separate  the 
posterior  border  of  the  liver  from  the  diaphragm,  and  divide  the  inferior  layer  of  the  coronary  ligament. 
Divide  the  vena  cava  just  above  the  posterior  border,  and  again,  just  below  it.  Cut  the  ligaments  close 
to  the  abdominal  wall,  so  that  their  connection  with  the  liver  can  be  studied  when  the  organ  is 
removed. 

The  liver. 

Relation  to  the  peritoneum,  1018-19.     (996-7) 
Ligaments  of  the  liver,  1019.     (997) 

Coronary  ligaments. 

Right  and  left  lateral  ligaments. 

Broad  ligament. 

Round  ligament. 

Carefully  expose  the  fissures  and  demonstrate  the  vessels,  ducts,  etc.,  entering  or  emerging  from 
the  liver. 

Inferior  surface,  posterior  surface,  fissures,  1014-15-16.     (992-3-4) 
Longitudinal  fissure:  — 

Umbilical  fissure. 

Fissure  of  the  ductus  venosus. 
Transverse  or  portal  fissure. 
Fossa  of  the  gall  bladder. 
Fissure  of  the  vena  cava. 
Spigelian  lobe.     Caudate  lobe. 
Gall  bladder,  1020-1-2-3.     (998-9-1000-1) 

Structure  of  the  gall  bladder. 


THE  ABDOMINAL    WALLS.  99 

\ 

Blood-vessels  of  the  liver.     Lymphatics,  1019-20.     (997-8) 
Hepatic  veins,  672.     (658) 
Lymphatics  of  the  liver,  703-4.     (688) 
Superficial  set  of  lymphatics. 
Upper  or  convex  surface. 

Superficial  lymphatics  on  the  under  surface  of  the  liver. 
Deep  set  of  lymphatics. 
Structure  of  the  liver,  1020.     (998) 
Varieties  of  the  liver,  1023.     (1001) 

Trace  the  portal  vein,  hepatic  arteries,  and  hepatic  ducts  in  a  portion  of  the  liver ;  in  another  portion, 
trace  the  hepatic  veins. 

The  kidneys: — 

Investment  and  fixation,  1043.     (1021-2-3) 

Remove  the  capsule  of  fat  and  connective  tissue  and  expose  the  kidney  and  suprarenal  body  in 
place.  Trace  the  vessels  leading  to  and  from  them ;  and  the  ureter,  from  the  kidney  to  the  brim 
of  the  pelvis. 

Physical  characters,  1042-3.     (1020-1) 
Anterior  or  visceral  surface. 
Posterior  or  parietal  surface. 
Upper  extremity. 

External  border.     Internal  border. 
Hilum.     Sinus. 
Varieties,  1050.     (1028) 

Position  and  relations,  1043-4-5-6-7.     (1023-4-5) 
Posterior  surface. 
Upper  extremity. 
Anterior  visceral  surface : — 
Right  kidney. 
Left  kidney : — 

Upper  or  gastric  area. 
Middle  or  pancreatic  area. 
Inferior  or  colic  area. 
Outer  border.     Inner  border. 
Structures  lying  within  the  sinus. 
Excretory  duct  of  the  kidney,  1051-2.     (1029-30) 
Superior  and  inferior  pelves. 
Common  pelvis,  ureter  proper. 
Ureter : — 

Course  and  relations  : — 
Abdominal  portion. 
Lymphatics  of  the  ureters,  705.     (689) 
Renal  arteries,  594.     (583) 

Branches :  —  Inferior  suprarenal. 

Capsular  or  perineal  branches. 
Uretal  branch. 

Variations  in  the  renal  arteries. 

Renal  plexus,  871.     (850-2) 

Renal  or  emulgent  veins,  670-1.     (656) 

Suprarenal  bodies,  1050.     (1028) 

Right  suprarenal  body,  anterior  surface. 

Left  suprarenal  body,  anterior  surface  : — 

Above.     Externally. 

Suprarenal  lymphatics,  705.     (689) 
Suprarenal  arteries,  595.     (584) 

Superior  suprarenals. 

Middle  suprarenals. 

Inferior  suprarenals. 


ioo  OUTLINES  OF  ANATOMY. 

Suprarenal  plexus,  871.     (850) 
Suprarenal  veins,  671.     (656) 
Right  side.     Left  side. 

On  the  right  side  divide  the  renal  and  suprarenal  arteries  and  veins,  divide  the  right  ureter  at  the  brim 
of  the  pelvis  and  remove  the  right  kidney  and  suprarenal  body  and  study  their  structure.  Leave  the 
left  kidney  in  place.  To  expose  the  structure  of  the  kidney,  divide  it  into  two  portions,  Fig.  613,  and 
divide  one  of  these  portions  into  two  lateral  halves,  Fig.  609 ;  from  these  sections  some  idea  of  the 
structure  can  be  obtained.  Divide  the  suprarenal  body  into  lateral  halves  and  examine  its  structure. 

Structure — of  the  kidney,  1047-8-9-50.     (1025-6-7-8) 
Medulla.     Cortex. 
Medulla  : — 

Pyramids  of  Malpighi : — 

Pyramids.     Papilla.     Calyx.     Foramina  papillaria. 
Cortex  : — 

Cortex  proper. 
Columnae  Bertini. 
Pyramids  of  Ferrein. 
Uriniferous  tubules,  collecting  tube. 
Vessels  : — 

Cortico — medullary  arches  : 
Cortical  arches. 
Medullary. 
Efferent  vessels. 

Lymphatics.     (Also  704.)     (689) 
Nerves. 

Suprarenal  bodies,  1050-1.     (1028-9) 
Structure  : — 
Cortex. 
Medulla. 
Vessels  and  nerves  : — 

Arteries.     Veins.     Lymphatics. 
Nerves. 

Expose  the  abdominal  aorta,  the  common  and  external  iliac  arteries,  also  the  inferior  vena  cava  and 
iliac  veins.  The  arterial  and  venous  tributaries  not  already  shown  should  now  be  exposed  in  the 
order  indicated.  In  exposing  the  aorta,  preserve  the  solar  plexus  and  semilunar  ganglia. 

The  abdominal  aorta,  584-5.     (573-4) 

Relations: — In  front.     Behind.     Right  side.     Leftside. 

Variations. 

Branches : — 

Right  and  left  phrenic,  586-7.     (575-6) 
Right  phrenic. 

Branches  : — Anterior.     Posterior. 

Right  superior  suprarenal. 
Caval.     Hepatic.     Pericardial. 
Left  phrenic. 

Branches  : — Anterior.     Posterior. 

(Esophageal.     Left  superior  suprarenal. 
Splenic.     Pericardial. 
The  diaphragmatic  plexuses,  871.     (850) 
Phrenic  veins  or  inferior  phrenic  veins,  672.     (658) 
Diaphragmatic  lymphatics,  696.     (681) 
Spermatic  arteries,  595-6.     (584) 

Branches  : — Uretal.     Cremasteric. 

Chief  variations  in  the  spermatic  arteries. 

Spermatic  plexus,  871.     (852) 
Spermatic  veins,  671.     (656-7) 
Lymphatics  of  the  testicle,  702.     (687) 


THE   ABDOMINAL    WALLS.  101 

Ovarian  arteries,  596.     (585) 

Branches: — Uretal.     Fallopian.     Uterine.     Ligamentous. 
Ovarian  veins,  671.     (652) 

Common  iliac  arteries,  598-9  ;  Fig.  363.     (587-8) 
Right  common  iliac. 

Relations : — In  front.     Behind.     Right  side.     Left  side. 
Left  common  iliac. 

Relations  : — In  front.     Behind.     Left  side.     Right  side. 
Variations  in  the  Common  Iliac  Arteries,  _$99-     (j^8) 
Collateral  circulation,  600.     (588) 
Branches  of  the  common  iliac  arteries,  600.     (589) 

Peritoneal.     Subperitoneal.     Ureteric. 
Internal  iliac  artery,  600.     (589) 
External  iliac  artery,  611-12.     (600) 

Relations  : — In  front.     Behind.     Inner  side.     Outer  side. 
Variations. 

Branches  of  the  external  iliac  artery,  612-13.     (600-1-2) 
Deep  epigastric  artery. 

Variations. 

Deep  circumflex  iliac. 
Variations. 

External  iliac  vein,  686-7.     (672) 

Tributaries: — Deep  epigastric  vein. 

Deep  circumflex  iliac  vein. 
Common  iliac  veins,  672.     (658-9) 

Right  vein.     Left  vein. 

Chief  Variations  in  the  Common  Iliac  I'eins,  673.     (659) 

The  inferior  or  ascending  vena  cava,  669-70.     (656) 
Relations: — In  front.     Behind.     Right.     Lett. 
Tributaries. 

Chief  Variations  in  the  Inferior  Vena  Cava,  672.     (6j8) 

Solar  plexus,  870.     (850) 

Semilunar  ganglia. 

Parietal  lymphatic  glands,  700-1.     (685-6) 
External  iliac  lymphatic  glands. 
Sacral  glands. 
Lumbar  glands  :  — 

Median  group.     Left  lumbar  lymphatic  trunk. 
Lateral  lumbar  glands.     Transverse  lumbar  or  psoas  glands. 
Thoracic  duct,  698.     (683) 

Abdominal  portion  of  the  thoracic  duct. 

Receptaculum  chyli  or  cistern  of  Pecquet. 
Gangliated  cords  of  the  sympathetic,  864.     (844) 

Rami  communicantes : — 

\Vhite  ramus  communicans. 
Gray  ramus  communicans  or  revehent  nerve. 
Afferent.     Efferent. 

Lumbar  part  of  the  gangliated  cord,  869.     (848-9) 

Rami  communicantes.     Branches. 
Lumbar  arteries  (origin),  587.     (576) 
Lumbar  veins  (termination),  671—2.     (657-8) 

Ascending  lumbar  vein. 
Azygos  veins,  642-3-4.     (630-1-2) 
Vena  azygos  major. 

Relations  in  the  abdomen. 
Vena  azygos  minor,  lower  left  azygos  or  vena  hemiazygos. 


102  OUTLINES  OF  ANATOMY. 

Strip  the  peritoneum  from  the  under  surface  of  the  diaphragm  and  expose  that  muscle. 

Diaphragm,  423-4-5.     (419-20-1) 

Origin  : — Anterior  or  sternal  portion. 
Lateral  or  costal  portion. 
Posterior  or  vertebral  portion  : — 

Ligamentum  arcuatum  externum. 
Ligamentum  arcuatum  internum. 
Crus ;  right  side,  left  side. 
Insertion. 
Structure: — Central  tendon. 

Foramina. 

Nerve-supply.     Action.     Relations.     Variations. 
Iliac  fascia,  368-9.     (368)     Lumbar  fascia,  434.     (430) 

Carefully  reflect  the  fascia  from  the  surface  of  the  psoas,  iliacus,  and  quadratus  lumborum.  In  reflect- 
ing the  fascia,  avoid  injuring  the  branches  of  the  lumbar  plexus  crossing  these  muscles. 

Psoas  magnus,  366-7.     (365-6-7) 

Origin  : — Inner  part.     Outer  part. 

(Insertion.)     Structure.     Nerve-supply.     Action.     Relations.     Variations. 
Psoas  parvus,  368.     (367-8) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Iliacus,  368.     (367) 

Origin.    (Insertion.)   Structure.    Nerve-supply.    Action.    Relations.  Variations. 

Carefully  expose  the  branches  of  the  lumbar  plexus,  tracing  them  from  their  origin  to  the  point  of  exit 
from  the  abdominal  cavity.  To  expose  the  nerves  at  their  origin  it  will  be  necessary  to  dissect  away  a 
portion  of  the  psoas  muscle. 

Lumbar  nerves,  846.     (826) 
Lumbar  plexus,  846-7.     (827-8-9) 
Branches: — 

Ilio-hypogastric  nerve,  848.     (829) 

Ilio-inguinal  nerve,  849.     (829) 

Genito  crural  nerve,  849.     (829) 

External  cutaneous  nerve,  851.     (832) 

Anterior  crural  nerve,  851-2.     (832) 
Nerves  to  the  iliacus. 

Obturator  nerve,  849.     (829-30) 

Accessory  obturator  nerve,  850.     (831-2) 

Quadratus  lumborum,  435-6.     (431) 

Origin.     Insertion.     Structure.     Nerve -supply.     Action.     Relations. 
Last  thoracic  nerve,  846.     (826-7) 
Subcostal  artery  or  twelfth  dorsal,  583.     (572~3) 
Subcostal  vein  or  twelfth  thoracic  vein,  645.     (633) 
Lumbar  arteries,  587-8.     (576) 

Muscular  branches.     Renal  branches. 

Variations. 

Lumbar  veins,  671-2.     (657-8) 
Anterior  branches. 
^Posterior  branches.) 

The  Pelvic  Viscera. 

Review  the  relations  of  (he  peritoneum  in  the  pelvic  cavity  and  note  the  plan  of  formation  of  the  peri- 
toneal ligaments. 

Recto-vesical  pouch,  992.     (971) 
Bladder  :— 

Peritoneum,  false  ligaments,  1056.     (1034) 


THE  ABDOMINAL    WALLS.  103 

-  Recto-vaginal  pouch,  1056.     (971) 
Ligaments — of  the  uterus  : — 

Peritoneal  ligaments,  1085-6-7.     (1062-3-4) 

Lateral  or  broad  ligaments,  or  alae  vespertilionis. 
Superior  or  free  border. 

Ligamentum  infundibulo-pelvicum. 
Internal  border. 
Inferior  border. 
_-,  External  border. 

Structures  enclosed  between  the  two  layers  of  the  broad  liga- 
ment : — 

(1)  The  ovary  and  its  ligament. 

(2)  Fallopian  tube. 

(3)  Round  ligament. 

(4)  Parovarium.    Duct  of  Gartner.    Hydatid  of  Morgagni. 
Posterior  peritoneal  or  recto-uterine  ligaments. 

Utero-sacral  ligaments. 
Anterior  peritoneal  or  utero-vesical  ligaments. 

Strip  the  peritoneum  from  the  pelvic  walls,  with  the  knife-handle  carefully  scrape  away  the  subperi- 
toneal  tissue  and  fat  and  expose  the  upper  or  pelvic  segment  of  the  obturator  fascia  and  the  recto- 
vesical  fascia.  The  ligaments  of  the  bladder  will  be  developed  as  the  recto-vesical  fascia  is  traced. 

Subperitoneal  connective  tissue,  994.     (973) 
Obturator  fascia,  1098-9;  Fig.  684.     (1075) 

White  line  or  arcus  tendineus. 

Upper  or  pelvic  segment. 
Recto-vesical  fascia,  1101-2,  1056.     (1077,  1034) 

Prostatic  or  anterior  true  ligaments. 

Lateral  true  ligaments. 

Superior  true  ligament. 
The  pelvic  fascia,  1156.     (1132) 

The  relations  of  the  pelvic  fascia  should  also  be  studied  with  a  pelvis  in  which  the  fascia  has  been 
exposed  from  the  side,  by  the  removal  of  a  part  of  the  pelvic  wall. 

The  position,  relations,  form,  and  size  of  each  of  the  pelvic  organs  should  now  be  determined,  so  far  as 
is  possible  without  dissection  or  injury  to  the  structures. 

The  rectum.     The  anus,  ion.     (989-90) 
Urinary  bladder,  1053-4-5-6.     (1031-2-3) 
Form. 

Relations  : — Antero-inferior  surface.     Cavum  Retzi. 
Lateral  surface. 

Posterior  surface.     Triangular  space. 
Superior  surface. 
In  the  infant,  1058.     (1035-6) 

A,  ,        (  Effects  of  distention.        ) 
Male.     \  T   .  \    loss— 6. 

(  Internal  urinary  meatus.  j 

Female  bladder,  1058.     (1038) 
Ureter,  pelvic  portion,  1052-3.     (1030-1) 
'  Vas  deferens,  1065-6.     (1043-4) 
'{  Vesiculae  seminales,  1066—7.     (1044-5) 
Male.  -|  Prostate,  1058-9.     (1036-7) 

Base.     Anterior  wall.     Posterior  wall. 
Prostatic  fissure. 


IO4 


OUTLINES  OF  ANATOMY. 


Recto-vaginal  pouch. 
Broad  ligaments. 


f  Uterus  or  womb,  1081-2-3-4.     (1058-9-60-1) 
Isthmus. 
Body:— 

Anterior  surface. 
Posterior  surface 
Superior  border. 
Lateral  borders. 
Superior  angles. 
Fundus. 
Cervix  : — Supravaginal  zone. 

Zone  of  vaginal  attachment. 
Intravaginal  zone,  or  os  uteri.     Labia. 
Dimensions. 
Direction. 

Variations  in  form  according  to  age. 
Female.  \  Muscular  ligaments,  1087-8.     (1064-5) 

Round  or  utero-inguinal.     Canal  of  Nuck. 
Utero-sacral  ligaments. 
Utero-pelvic  ligaments. 
Utero-ovarian. 

Ovary: — Form,  position,  etc.,  1090.     (1066-7) 
Fallopian  tubes,  1088-9.     (IQ65-6) 
Fimbrise.     Fimbria  ovarica. 
Isthmus.     Ampulla. 
Position. 

Vagina,   1079-80-1.     (1056-7-8) 
Form  and  direction. 
Relations:  — 
Anteriorly. 

Posteriorly.     Pouch  of  Douglas. 
Laterally.     Duct  of  Gartner. 

The  internal   iliac  artery  and  its  branches  should  now  be  exposed,  and  the  branches  followed  to  the 
organ  or  part  to  which  they  are  distributed,  or  to  the  place  of  exit  from  the  pelvis. 

Internal  iliac  artery,  600.     (589) 
Relations: — 
Behind. 
In  front. 

Variations. 

Branches  of  the  anterior  division  :  — 
Hypogastric  artery,  604.     (593) 
Vesical  arteries,  604-5.     (593) 
Superior  vesical : — 

Deferential  or  artery  of  the  vas  deferens.     (Male.) 
Uracheric  branch. 
Ureteric  branches. 
Middle  vesical. 
Inferior  vesical. 

Accessory  pudic. 


THE  ABDOMINAL    WALLS.  105 

Ovarian  artery,  596,  1091-2.     (585,  1068) 
Branches  : — Uretal. 

Fallopian. 
Uterine. 
Ligamentous. 

Funicular  artery,  1092.     (1068) 

Female.  \  Uterine  artery,  605-6,  1091.     (594,  1067-8) 
Branches  of  the  uterine  artery  : — 
Cervical. 
Vaginal  azygos. 

Vaginal  arteries,  606.     (594-5) 
Azygos  artery  of  the  vagina. 
Uterine  veins.     Ovarian  veins,  1091-2.     (1068) 

Middle  haemorrhoidal  or  middle  rectal  artery,  605.     (593-4) 

Obturator  artery,  606-7.     (595) 

Iliac  or  nutrient  branch. 
.   Vesical. 

Pubic  branch. 
Sciatic  artery,  607.     (595-6) 

Intrapelvic  branches. 

Internal  pudic  artery — within  the  pelvis,  608.     (597) 
Branches  of  the  posterior  division  of  the  internal  iliac  artery : — 
Ilio-lumbar  artery,  601-2.     (589-90-1) 
Iliac  branch. 
Lumbar  branch. 
Gluteal  artery,  602-3.     ($9 0 

Branches — within  the  pelvis. 
Lateral  sacral  arteries,  602.     (591) 
Superior  artery. 
Inferior  lateral  sacral  :  — 

Posterior  or  spinal  branches. 
Anterior  or  rectal  branches. 
External  branches. 
Internal  branches. 
Middle  sacral  artery,  598. 
Lateral  sacral  branches. 
Rectal  or  haemorrhoidal  branches. 

Variations. 

Fifth  pair  of  lumbar  arteries,  688.     (577) 
Middle  sacral  veins,  672-3.     (659) 
Veins  of  the  pelvis,  676-7-8.     (663-4) 
Internal  iliac  vein  :  — 

Tributaries  : — Gluteal  veins.     Ilio-lurnbar  veins.     Lateral  sacral  veins. 
Obturator  vein.     Sciatic  veins.     Pudic  vein. 
Prostatico  vesical  plexus  (male).     Vesical  plexus. 
Haemorrhoidal  plexus  of  veins  : — 

Inferior,  middle,  superior. 
Lymphatics  of  the  pelvic  viscera,  702.     (686) 
Lymphatics  of  the  bladder. 
Lymphatics  of  the  rectum. 

The  lymphatics  of  the  uterus,  vagina,  ovaries,  and  Fallopian  tubes. 
Pelvic  walls,  700.     (685) 

Draw  the  pelvic  organs  aside,  strip  off  the  recto- ve^cal  fascia  and  expose  the  visceral   surface  of  the 
levator  ani  and  coccygeus  muscles. 

Levator  ani  muscle,  1099-1100.     (1075-6) 
Coccygeus,  noo-i.     (1076-7) 


io6  OUTLINES  OF  ANA  TOM). 

Draw  the  pelvic  organs  forward  and  expose  the  sacral  and  coccygeal  nerves.  Trace  the  branches  to 
their  distribution  or  to  the  place  of  exit  from  the  pelvic  cavity. 

Sacral  and  coccygeal  nerves,  853;  Fig.  465.     (833) 
Fourth  sacral  nerve  :  — 

Perforating  cutaneous  branch. 
Perinseal  branch. 

Branches  to  coccygeus  and  levator  ani. 
Coccygeal  plexus,  854.     (834) 
Anterior  branches. 
Posterior  branches. 
Coccygeal  nerve. 

Sacral  plexus;  great  sciatic  nerve,  pudic  nerve,  854;  Fig.  465.     (834) 
"Branches  of  the  sacral  plexus,"  collateral  and  terminal. 
Collateral  branches: — 

Superior  gluteal  nerve,  854-5.  (835) 
Inferior  gluteal  nerve,  855.  (835-6) 
Nerve  to  the  pyriformis,  855.  (836) 
Visceral  branches. 

Nerve  to  the  quadratus,  855-6.     (836) 
Small  sciatic,  856-7.     (837-8) 
Nerve  to  the  obturator  internus,  857.     (837-8) 
Terminal  branches: — 

Great  sciatic  nerve,  858.     (838-9) 
Pudic  nerve,  857-8.     (838) 

Expose  the  hypogastric  plexus  and  the  sacral  portion  of  the  gangliated  cord  and  note  the  branches  of 
communication  with  the  sacral  plexus.  So  far  as  possible,  trace  the  branches  of  distribution  to  the 
pelvic  viscera. 

Hypogastric  plexus,  871.     (852) 
Pelvic  plexuses,  873.     (852-3) 
Middle  hemorrhoidal  plexus. 
Vesical  plexus: — 
Superior  group. 
Inferior  group. 

Nerves  to  the  vas  deferens  (male). 
Prostatic  plexus  (male). 
Small  cavernous  nerve. 
Large  cavernous  nerve. 
Vaginal  plexus  (female). 
Uterine  plexus  (female). 

Sacral  part  of  the  gangliated  cord,  869.     (849) 
Rami  communicantes. 
Branches. 
Male. — Suspensory  ligament  of  the  penis.     Angle  of  the  penis,  1070.     (1047) 

Remove  the  organs  from  the  pelvic  cavity  and  study  their  structure.  To  remove  the  organs,  divide  the 
vessels  and  nerves  passing  to  them  ;  draw  the  bladder  and  rectum  away  from  the  pelvic  walls  and  care- 
fully sever  the  connecting  fascia  and  ligaments ;  (in  the  male;  draw  the  penis  downward  and  free  it 
from  its  attachments  to  the  pubic  arch,  cutting  the  crura  and  ligaments  close  to  the  arch) ;  finally,  divide 
the  levator  and  sphincter  ani  muscles.  The  left  kidney  and  ureter  should  be  removed  with  the 
bladder. 

Carefully  separate  the  rectum  from  the  bladder  (and  prostate,  in  the  male ;  uterus  and  vagina,  in  the 
female) ;  inflate  it  and  demonstrate  the  internal  sphincter,  and  its  coats. 

The  rectum,  1011—12.     (989-90) 
The  anus. 

Divide  the  left  kidney  by  a  vertical  incision,  extending  from  the  outer  border  nearly  to  the  hilum,  open- 
ing the  sinus  and  exposing  the  interior  of  the  pelvis.  Insert  the  blowpipe  in  the  pelvis  of  the  kidney 
and  inflate  the  bladder  through  the  ureter,  a  ligature  being  placed  around  the  ureihra.  Clean  the 
surface  of  the  bladder  (remove  the  bladder  from  the  vagina  and  uterus,  in  the  female),  exposing  the 
terminal  portion  of  the  ureters,  also  the  vas  deferens  and  the  vesiculas  seminales,  then  carefully  expose 
the  prostate  and  the  membranous  portion  of  the  urethra,  with  Cowper's  glands.  (In  the  female,  ex- 
pose the  ureters  and  urethra.) 


THE   ABDOMINAL     WALLS.  107 

The  ureter,  pelvic  portion,  1052-3.     (1030-1) 
Reproductive  organs  of  the  male,  1058.     (1036) 
The  testicles,  1061-2-3-4-5.     (1038-9-40-1) 
The  testicle  proper. 
The  epididymis :  — 
Globus  major. 
Globus  minor. 
Tunica  vaginalis. 

Gubernaculum  testis.     Internal  cremaster  of  Henle. 
Processus  vaginalis. 
Structure :  — 

Tunica  albuginea : — 

Mediastinum  testis  or  corpus  Highmorianum. 
Trabeculae. 
Tunica  vasculosa. 
Tubuli  seminiferi,  spermatozoa. 

Lobules.     Tubuli  recti.     Rete  testis.     Vasa  efferentia. 
Epididymis: — 

Conus  vasculosus.     Tube  of  the  epididymis.     Vas  deferens. 
Vas  aberrans. 
Hydatid  of  Morgagni. 
Paradidymis,  or  organ  of  Giraldes. 

Vessels  and  nerves  of  the  testicle  and  its  appendages,  1067-8.     (1045) 
Arteries.     Veins.     Lymphatics  of  the  vas  and  testicle. 
Nerves. 

Open  the  vas  deferens  by  a  short  longitudinal  incision  about  four  inches  above  its  termination,  insert 
the  end  of  a  small  blowpipe,  and  inflate  the  lower  portion  of  the  vas  deferens  and  the  seminal  vesicle; 
they  can  then  be  readily  exposed  by  careful  dissection. 

Vas  deferens,  1065-6.     (1043-4) 

Ejaculatory  duct. 
Vesiculae  seminales,  1066-7.     (I044~5) 

Ejaculatory  duct. 
Urinary  bladder :  — 

Structure,  1056-7-8.     (1033-4-5) 

Muscular  coat,  diverticular  sacculations. 
Submucous  coat. 

Open  the  bladder  by  a  median  vertical  incision  through  the  anterior  wall,  extending  from 
the  summit  to  the  base ;  continue  the  incision  along  the  median  line  of  the  urethra  (divid- 
ing the  prostate  and  open'ng  the  membranous  portion  of  the  canal,  in  the  male).  Spread 
out  the  bladder  and  display  its  inner  surface. 

Mucous  membrane. 

Trigone.     Plica  ureterica.     Uvula  of  Lieutaud. 
Vessels : — 

Arteries.     Veins.     Lymphatics. 
Nerves. 
Ureter,  vesical  portion,  1053.     (1031) 

Insert  a  small  probe  in  the  lower  portion  of  the  ureter ;  with  the  point  of  the  knife  open  the  canal  and 
trace  it  through  the  bladder  wall. 

Structure : — 

Mucous  membrane. 

Muscularis. 
Vessels  and  nerves : — 

Arteries.     Veins.     Lymphatics. 

Nerves. 
Varieties. 
The  female  urethra,  1079.     (I056) 


io8 


OUTLINES   OF  ANATOMY. 


1060.     (1037-8) 
Lymphatics. 


Male.  - 


The  urethra,  1073-4-5.     (1050-1-2) 
Prostatic  portion  : — 

Collicus  seminalis  or  verumontanum. 

Sinus  pocularis  or  uterus  masculinus. 

Ejaculatory  ducts. 

Prostatic  sinuses. 
Membranous  portion. 
Prostate  : — 

Structure  and  function , 
Vessels  and  nerves  :  — 

Arteries.     Veins. 

Nerves. 

Insert  a  small  probe  in  the  ejaculatory  duct;   with  the  point  of  the  knife  trace  the  duct  to 
the  vas  deferens  and  the  vesicula  seminalis. 

The  penis,  1069-70-1-2.     (1046-7-8-9) 
Corpora  cavernosa. 
Corpus  spongiosum. 
Root.     Body.     Neck.     Glans. 
Coverings  of  the  penis: — 

Prepuce.     Fraenum  prasputi. 

Remove  the  skin  from  the  surface  of  the  penis,  expose  and  trace  the  dorsal  vein, 
arteries,  and  nerves.  Insert  the  point  of  a  small  blowpipe  in  the  dorsal  vein  and  dis- 
tend with  air. 

Dorsal  vein  of  the  penis,  677.     (663) 
Dorsal  artery  of  the  penis,  611.     (599) 
Dorsal  nerve  of  the  penis,  858.     (838) 
Superficial  lymphatics  of  the  penis,  700.     (685) 
Dartos.     Fascial  sheath,  1070.     (1047) 

Reflect  the  fascial  sheath,  and  expose  the  corpora  cavernosa  and  corpus  spongiosum. 

Corpora  cavernosa.     Crus  penis. 

Tunica  albuginea.     Septum  pectiniforme. 
Corpus  spongiosum  :  — 

Glans: — Corona  glandis.     Neck.     External  urinary  meatus. 

Body. 

Bulb. 

Open  the  spongy  portion  of  the  urethra  by  a  median  incision,  and  examine  the 
mucous  membrane. 

Urethra,  spongy  portion,  1075.     (1052) 
Penile  angle. 
External  meatus. 
[  Lacunae.     Lacuna  magnus. 

Female  Reproductive  Organs  :     Structure. 

Carefully  clean  and  expose  the  uterus  and  vagina ;   spread  them  out,  with  the  posterior  surface 
uppermost,  and  demonstrate,  first,  the  structure  of  the  vaginal  wall. 

Vagina: — Structure,  1 08 1.     (1058) 
Fibrous  coat. 
Muscular  coat. 

Open  the  vagina  by  a  median  incision  through  the  posterior  wall;  make  a  short  transverse 
incision  at  the  upper  end  of  the  median  incision,  and  reflect  the  vaginal  wall  outward, 
Fig.  635.  Note  the  relations  of  the  vaginal  wall  to  the  cervix. 

Mucous  membrane. 
Vessels  and  nerves  : — 

Arteries.     Veins.     Lymphatic?. 

Nerves. 


THE  ABDOMINAL    WALLS.  109 

Uterus,  1083-4-5.     (1060-1-2) 
Cervix  : — 

Supra-vaginal  zone. 
Zone  of  vaginal  attachment. 
Intra-vaginal  zone,  os  uteri. 
Labia. 

Open  the  uterus  by  a  Y-incision ;  beginning  at  tbe  os,  make  a  median  incision  through  the 
posterior  wall  nearly  to  the  fundus,  and  from  the  upper  end  of  the  median  incision  make 
incisions  in  the  direction  of  the  angles,  to  tbe  termination  of  the  oviducts,  Fig.  637.  Start- 
ing at  the  median  incision,  trim  away  the  posterior  wall  of  the  uterus  and  expose  the  cavity. 

Cavity : — 

Cavity  of  the  body. 
Cavity  of  the  neck. 
Os  internum. 
Os  externum. 
Structure  : — 

Muscular  coat. 

Outer,  middle  layer,  internal  layer. 
Mucous  membrane. 

Uterine  artery.     Uterine  veins,  1091.     (1067-8) 
Lymphatics,  1092.     (1068—9) 
Fallopian  tube. 

Structure,   1089—90.     (1066) 
Serous  coat. 
Cellular  coat. 
Muscular  coat. 
Mucous  membrane. 
Ovary,  1090—1.     (1067) 
Structure  : — 

Tunica  albuginea. 

Ovisacs  or  Graafian  follicles.     Corpus  luteum. 
Ovarian  artery.     Ovarian  veins,  1091-2.     (1068) 
Read: — Development  of  the  Genito-urinary  Organs,  1091-1096.     (1069—1072) 

The  Thigh,  1210-1216.     (1186-1192) 
Bony  landmarks : — 

Trochanter  major.     Nelaton'sline.     Bryant's  triangle. 
Muscular  prominences.     Poupart's  ligament. 
Scarpa's  triangle.     Saphenous  open  ing. 
Line  of  femoral  artery.     Hunter's  canal. 

The  Knee,  1220-2-3-4.     (1196-7-8-9-1200) 
Bony  landmarks  : — 
The  patella. 

In  extension.     In  flexion.     In  semiflexion. 
Dislocation  of  the  patella. 
The  condyles  and  tuberosities. 
Ligamentum  patellae  and  tubercle  of  the  tibia. 
Prepatellar  bursa. 
Synovial  membrane  ;  Fig.  769. 

Dissection  of  the  Front  of  the  Thigh. 

With  crayons  indicate  the  distribution  of  the  cutaneous  nerves  on  the  anterior  aspect  of  the  thigh,  Fie. 
464;  P.  851. 

Make  an  incision  from  the  anterior  superior  spine  of  the  ilium  along  the  line  of  Poupart's  ligament  to 
the  symphysis  pubis  and  from  the  pubis  backward,  between  the  scrotum  and  the  thigh,  als  >,  from  the 
middle  of  Poupart's  ligament  down  the  middle  of  the  thigh  and  knee  to  the  lower  end  of  the  tubercle 
of  the  tibia.  Make  transverse  incisions  at  the  middle  of  the  thigh,  above  and  below  the  knee.  Turn 
the  skin  each  way  from  the  median  incision,  exposing  the  superficial  fascia,  vessels,  and  nerves. 
Fig.  710;  P.  1165. 


no  OUTLINES  OF  ANATOMY. 

Superficial  fascia,  364.     (363) 

Superficial  epigastric  artery,  618.     (606) 

Superficial  circumflex  iliac  artery,  618.     (606) 

Superficial  external  pudic  artery,  618.     (606) 

Veins  :  —  Each  artery  is  accompanied  by  one  or  sometimes  by  two  veins;  these  veins 

open  into  the  saphenous  or  femoral  vein  ;  Fig.  397  ;  P.  684.     (670) 
Superficial  lymphatic  glands,  705  ;  Fig.  400.     (691) 
The  inguinal  glands  :  — 

Oblique  or  inguinal  glands  proper. 

Vertical  set,  or  saphenous  or  superficial  femoral  glands. 
Long  or  internal  saphenous  vein,  683-5  '•>   Fig.  397.     (669) 
Cutaneous  nerves,  P.  851  ;  Fig.  464.     (831) 
External  cutaneous  nerve,  851.     (832) 

Posterior  branch.     Anterior  branch. 
Crural  branch  —  of  the  genito-crural  nerve,  849.     (829) 
Terminal  branches  —  of  the  ilio-inguinal  nerve,  849.     (829) 
Middle  cutaneous  nerve,  852.     (832) 
Internal  cutaneous  nerve,  852.     (832) 

Anterior  branch.     Posterior  branch. 
Branches  of  the  long  or  internal  saphenous  nerve,  852-3. 
Patellar  branch. 

Plexus  patelle.     Subsartorial  plexus,  852.     (833) 
Turn  off  the  superficial  fascia  and  expose  the  deep  fascia  or  fascia  lata. 

Deep  fascia  or  fascia  lata,  364-5  ;  Fig.  285. 
Ilio-tibial  band. 

Saphenous  opening.     Iliac  portion.     Falciform  ligament. 
Pubic  portion.     Cribriform  fascia. 

Femoral  Hernia,  1165-6-7-8-9.     (1141-2-3-4-5) 
Parts  concerned  in  femoral  hernia  :  — 

(1)  Skin  and  superficial  fascia  of  groin. 

(a)  Superficial  layer  of  superficial  fascia. 

(b)  Deep  layer  of  superficial  fascia. 

(2)  Poupart's  ligament. 

(3)  Gimbernat's  ligament. 

(4)  Fascia  lata  :  —  Iliac  portion  ;    pubic  portion. 

(5)  Saphenous  opening. 


ce  an  incision  through  the  fascia  lata  from  near  the  anterior  superior  spine  of  the  ilium,  along  the 
lower  border  of  Poupart's  ligament  to  the  pubes,  and  from  the  same  point,  along  the  inner  border  of  the 
sartorius  for  about  five  inches.  Carefully  reflect  the  fascia  lata  down  and  in  and  expose  the  femoral 
sheath  in  place. 

(6)  Femoral  sheath. 

Beginning  just  below  Poupart's  ligament,  make  a  vertical  incision  about  two  inches  in  length  through 
the  femoral  sheath,  and  expose  the  femoral  artery  ;  in  the  same  manner,  expose  the  vein  and  the  femoral 
canal  at  the  inner  side  of  the  vein.  Demonstrate  the  septum  between  the  canal  and  the  vein,  and 
between  the  vessels. 

(7)  Femoral  canal  :  — 

Length.     Limits.     Boundaries.     Contents. 

(8)  Femoral1  ring  :  —  Shape.     Boundaries. 

Position  of  vessels  around  the  ring. 
Course  of  femoral  hernia. 
Coverings  of  a  femoral  hernia  :  — 

(A)  At  upper  or  femoral  ring. 

(B)  In  the  canal. 

(C)  At  the  external  or  superficial  opening. 
Scarpa's  triangle. 

Carefully  remove  the  deep  fascia  from  the  upper  third  of  the  thigh,  exposing  the  muscles  forming  the 
boundaries  of  Scarpa's  triangle.  Dissect  out  the  fat,  fascia,  and  connective  tissue,  and  expose  the  vessels 
and  nerves  in  the  triangle,  and  the  muscles  forming  its  floor. 


THE  ABDOMINAL    WALLS.  in 

The  femoral  artery,  613-14-15-16;  Fig.  372.     (602-3-4,  606) 
Relations  of  the  common  femoral  artery  : — 

In  front.    Behind.     Inner  side.     Outer  side. 
Relations  of  the  superficial  femoral  artery  in  Scarpa's  triangle  : — 

In  front.     Behind.     Outer  side.     Inner  side. 
Branches  of  the  femoral  artery  : — 

(A)  From  the  common  femoral,  618.     (606) 

(i),  (2),  (3),  already  shown. 

(4)  Deep  or  inferior  external  pudic  artery. 

(5)  Profunda  or  deep  femoral  (followed  later). 

(B)  From  the  superficial  femoral  in  Scarpa's  triangle,  621.     (609) 

Muscular.     Saphenous. 

Reflect  the  fascia  lata  from  the  front  and  inner  side  of  the  thigh,  knee,  and  upper  portion  of  the  leg. 
Expose  and  separate  the  muscles,  as  indicated.  The  vessels  and  nerves  will  be  exposed  as  the  muscles 
are  separated,  and  should  be  traced  to  their  place  of  distribution  or  followed  through  the  region. 

The  sartorius,  369-70  ;  Fig.  287.     (368-9) 

Origin.     Insertion.     Structure.     Nerve-supply.   Action.   Relations.    Variations. 

Follow  the  superficial  femoral  artery  down  the  thigh,  separating  the  muscles  to  expose  the  vessel.  Note 
the  relations  of  each  portion. 

Line  of  the  femoral  artery.     Hunter's  canal,  1213-14-15.     (1189-90-1-2) 
Open  the  canal  and  expose  the  vessels. 

Relations  of  the  superficial  femoral  artery  in  Hunter's  canal,  616^     (604) 

In  front.     Behind.     Inner  side.     Outer  side. 

Branches  of  the  superficial  femoral  in  Hunter's  canal,  621.     (609) 
Muscular  branches. 
Anastomotica  magna : — 
Superficial  branch. 
Deep  branch. 
The  femoral  vein,  686.     (672) 

Tributaries. 

The  common  femoral  vein,  internally,  686.     (672) 
Tributary. 

Chief  variations. 

Deep  inguinal  or  deep  femoral  glands,  707.     (691) 
Anterior  crural  nerve,  851-2-3  ;  Fig.  463.     (832-3) 
Branches: — Nerve  to  pectineus. 

Middle  cutaneous  nerve. 
Nerve  to  the  sartorius. 
Internal  cutaneous  nerve. 

Anterior  branch.     Posterior  branch. 
Long  or  internal  saphenous  nerve. 
Xerves  to  the  quadriceps. 

Tensor  vaginae  femoris,  373  (372);  Fig.  287,  P.  370  (369);  Fig.  303,  P.  429.  (425) 
Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Ilio-tibial  band,  364;  Fig.  287. 

Quadriceps  extensor  femoris,  387  (385);  Fig.  287,  P.  370.     (369) 
Rectus  femoris,  387-8.     (385-6) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
External  circumflex  artery,  619.     (607) 

Ascending  branch.     Transverse  branch.     Descending  branches. 

Variations  in  the  external  circumflex. 

Vastus  externus,  388.     (386) 

Origin.     Insertion.     Structure.     Nerve-supply. 
Vastus  internus  and  crureus,  388-9-90.     (386-7-8) 

Origin.     Insertion.     Structure. 

Ligamentum  patellae. 


ii2  OUTLINES  OF  ANATOMY. 

Vastus  Interims  and  Crureus  : — 
Nerve-supply.     Action. 

Relations  of  the  vastus  externus,  crureus,  and  vastus  internus. 
Variations. 

The  Inner  Side  of  the  Thigh. 

The  adductor  muscles,  379  ;  Figs.  287-9-90.     (377) 
Gracilis,  383;  (381-2) 

Origin.     Insertion.     Structure.     Nerve-supply.  '  Action.     Relations. 
Adductor  longus,  379  ;  Fig.  289.     (378-9-80) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  adductor  longus  just  below  its  origin  and  turn  the  muscle  downward  and  outward,  expos- 
ing the  profunda  or  deep  femoral  artery. 

Profunda  or  deep  femoral  artery,  618-19.     (607) 

Relations: — Behind.     In  front.     Externally.     Internally. 
Branches  of  the  profunda: — (a),  (b),  (c). 

(c)  Perforating  arteries  of  the  profunda,  620.     (608) 

Superior  or  first  perforating  ;  crucial  anastomosis. 
Middle  or  second  perforating. 
Inferior  or  third  perforating. 
Fourth  perforating. 

Profunda  or  deep  femoral  vein,  686.     (672) 
Pectineus,  370-1 ;  Fig.  287.     (370) 

Origin.    Insertion.     Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Cut  the  pectineus  at  its  origin  and  turn  it  downward  and  outward. 
Anterior  branch  of  obturator  nerve,  849.     (830) 
Accessory  obturator  nerve,  850.     (831-2)  > 

Internal  circumflex  artery ;  crucial  anastomosis,  619-20.     (607-8) 
Variations  of  the  internal  circumflex. 

Adductor  brevis,  380-1-2  ;  Fig.  289.     (380) 

Origin.     Insertion.     Structure.    Nerve-supply.     Action.    Relations.     Variations. 
Cut  the  adductor  brevis  at  its  origin  and  turn  downward  and  outward. 

Posterior  branch  of  obturator  nerve,  849-50.     (831) 
Adductor  magnus,  382-3;  Fig.  290.     (380-1) 

Origin.     Insertion.     Structure.    Nerve-supply.    Action.    Relations.   Variations. 

Gluteal  Region,  1216-17-19-20.     (1192-3-5-6) 
Bony  landmarks. 
Gluteus  maximus. 
Nerves  and  vessels  :  — 

Superficial  nerves,  P.  1246;  Fig.  791.     (1222) 

Great  sciatic  nerve. 

Gluteal  artery. 

Sciatic  and  pudic  arteries. 

To  expose  the  structures  of  the  gluteal  region  :  Make  a  median  incision  from  the  spine  of  the  last  lum- 
bar vertebra  to  the  tip  of  the  coccyx,  make  a  transverse  incision  from  the  same  starting  point  to  the 
crest  of  the  ilium  and:  along  the  crest,  also,  a  curved  incision  from  the  coccyx  outward  and  downward 
to  the  posterior  median  line  of  the  thigh.  Remove  the  skin  over  the  gluteal  muscles  and  from  the  upper 
third  of  the  thigh  and  expose  the  superficial  fascia  and  nerves. 

Sacral  and  coccygeal  nerves,  828.     (808-9) 

External  branches  (see  internal  branches). 

Lower  two  sacral,  and  coccygeal  nerves. 
Lumbar  nerves,  827-8.     (808) 

External  branches  of  upper  three  nerves. 
Iliac  branch  of  the  ilio-hypogastric  nerve,  848.     (829) 
Iliac  branch  of  last  thoracic  nerve,  846.     (826) 


THE  ABDOMINAL    WALLS.  113 

Posterior  branch  of  external  cutaneous  nerve,  851.     (832) 
Reflected  branches  of  the  small  sciatic  nerve,  857.     (837) 

The  long  pudendal  nerve. 

Perforating  cutaneous  branch  of  fourth  sacral  nerve,  853.     (834) 
Lymphatics  of  the  gluteal  region,  705.     (689) 
Remove  the  fascia,  fat,  and  connective  tissue  and  expose  the  gluteus  maximus. 

Gluteus  maximus,  371-2-3  (370-1-2)  ;  P.  392  ;  Fig.  291.     (390) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  gluteus  maximus  near  its  origin,  beginning  at  the  anterior  border,  and  turn  it  downward  and 
outward  to  the  insertion  ;  much  care  is  required  to  raise  and  turn  off  the  muscle  without  injury  to  the 
underlying  structures.  A  number  of  vessels  and  nerves  will  be  seen  entering  the  inner  surface  of  the 
muscle  ;  these  should  be  carefully  divided  close  to  the  muscle,  as  it  is  reflected  to  the  insertion. 

The  inferior  gluteal  nerve,  855.     (835-6) 
Superficial  branch  of  the  gluteal  artery,  603.     (591) 
Gluteus  medius,  373-4;  Fig.  288.     (372-3) 

Origin.    Insertion.     Structure.     Nerve-supply.    Action.     Relations.     Variations. 

Beginning  at  the  posterior  border,  divide  the  gluteus  medius  about  two  inches  below  the  origin,  turn  the 
lower  portion  down  to  the  insertion,  carefully  raise  the  upper  portion  to  the  origin  and  expose  the  struc- 
tures underneath. 

Deep  branch  of  the  gluteal  artery,  604  :  Fig.  369.     (592) 

Superior.     Inferior  branch. 
Superior  gluteal  nerve,  854-5.     (835) 
Gluteus  minimus,  374-5  ;  Fig-  29°-     (373~4) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.     Relations.     Variations. 

Disarticulate  the  pelvis  and  lower  extremity  from  the  trunk,  dividing  the  spine  between  the  third  and 
fourth  lumbar  vertebrae.  Divide  the  pelvis,  cutting  one-half  an  inch  to  the  left  of  the  median  line  in 
front  and  behind. 

Pyriformis,  375-6-7;  Fig.  288.     (374) 

(Origin.)  Insertion.    Structure.   Nerve-supply.    Action.    Relations.    Variations. 
Sciatic  artery,  607-8  ;  Fig.  369.     (595-6) 
Branches  of  the  sciatic  artery  : — 
Intrapelvic  branches. 
Extrapelvic  brandies  : — 

Coccygeal.     Inferior  gluteal.     Muscular  branches. 
Anastomotic  branch,  crucial  anastomosis. 
Articular  branches.     Cutaneous  branches. 
Comes  nervi  ischiatici. 

Small  sciatic  nerve,  856-7  ;  Fig.  467.  (837) 
Great  sciatic  nerve,  858  ;  Fig.  467.  (838-9) 
Internal  pudic  artery,  608.  (596-7) 

As  it  crosses  the  spine  of  the  ischium  :  — 

Branches  of  the  artery. 

The  pudic  nerve  accompanies  the  artery,  857.     (838) 
Obturator  internus  and  gemelli,  377-8  ;  Fig.  288.     (374-5-6-7) 
Obturator  internus  : — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Gemellus  superior : — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Gemellus  inferior  : — 

Origin.     Insertion.     Structure.     Nerve-supply. 
Action.     Relations.     Variations. 
Quadratus  femoris,  378-9  ;  Fig.  288.     (377) 

Origin.  Insertion.    Structure.     Nerve-supply.    Action.    Relations.     Variations. 
Obturator  externus,  383-4.     (382) 

Insertion.     (The  muscle  will  be  shown  later.) 

The  parietal  structures  of  the  pelvic  cavity  not  already  fully  exposed,  should  now  be  demonstrated. 


ii4  OUTLINES  OF  ANATOMY. 

Pyriformis,  375.     (374) 

Origin.     Insertion.     Structure. 

Popliteal  Space,  1225-6-7-8.     (1200-1-2-3-4) 

The  popliteal  space  is  the  lozenge-shaped  space  or  hollow  placed  behind  the  knee- 
joint. 

Hollow  of  this  space. 
Popliteal  tendons.     Bursse. 
Popliteal  vessels  : — 

The  artery.     Popliteal  vein. 
Superior  articular  arteries  ;  inferior. 
The  external  saphenous  vein. 
Popliteal  glands. 

Expose  the  popliteal  space  by  a  median  incision  extending  from  a  point  six  inches  above,  to  one  four 
inches  below  the  joint;  make  transverse  incisions  at  each  end  of  the  median  incision.  Turn  the  skin 
each  way  from  the  median  incision,  exposing  the  superficial  fascia ;  in  the  superficial  fascia  will  be 
found  terminal  branches  of  the  small  sciatic  nerve  and  the  upper  portion  of  the  internal  saphenous 
vein. 

Branches  of  small  sciatic  nerve,  856-7.     (837) 
Short  or  external  saphenous  vein,  685.     (669-71) 
Deep  fascia  of  the  leg,  390.     (388) 

Turn  off  the  deep  fascia  in  the  same  manner  as  the  integument,  carefully  remove  the  fat  and  connec- 
tive tissue  from  the  space,  exposing  the  muscular  boundaries  and  the  structures  in  the  space. 

The  muscular  boundaries  of  the  popliteal  space  are  : — 

Above — Externally  :  Biceps — 384 — .     (382) 

Internally:  Semi-tendinosus — 385 — .  (383)  Semi-membranosus — 386 — (384)  Gra- 
cilis — 383 — .  (381)  Sartorius  (369) — 368 — Tendon  of  adductor  mag- 
nus — 382 — .  (380) 

Below — Externally:  Plantaris — 393 — ,  (391)     and  outer  head  of  gastrocnemius. 
Internally:  Inner  head  of  gastrocnemius — 391 — .     (389) 

At  the  upper  end  of  the  popliteal  space  the  great  sciatic  nerve  divides  into  two  large  trunks,  the  internal 
and  the  external  popliteal  nerves. 

The  internal  popliteal  nerve,  86 1.     (841) 

Cutaneous  branch  or  nervus  communicans  tibialis. 

Muscular  branches. 

Articular  branches. 
The  external  popliteal  nerve,  859.     (839) 

Cutaneous  branches.     Nervus  communicans  peronei. 

Articular  branches.     Recurrent  articular  nerve. 
The  popliteal  vein,  686.     (671) 

Chief  variations  of  the  popliteal. 

Popliteal  artery,  621-2-3.     (609-10-11) 

Relations: — In  front.     Behind.     Inner  side.     Outer  side. 

Principal  variations  in  the  popliteal. 

Branches  of  the  popliteal  artery,  623-4-5.     (612-13) 
Cutaneous  branches. 
Muscular  or  sural  branches  : — 

Upper  muscular  or  superior  sural. 
Inferior  muscular  or  sural  branches. 
Articular: — 

Superior  external  articular. 
Superior  internal  articular. 
Inferior  internal  articular. 
Inferior  external  articular. 
Azygos  articular. 

Geniculate  branch  of  the  obturator  nerve,  850.     (831) 
Popliteal  glands,  707.     (691) 


THE   ABDOMINAL    WALLS.  115 

Back  of  the  Thigh. 

Continue  the  median  incision  on  the  back  of  the  thigh  and  turn  off  the  skin.  In  the  superficial  fascia 
will  be  found  cutaneous  branches  of:  The  small  sciatic,  856-7  (837) ;  External  cutaneous,  85 1  (832) ; 
Internal  cutaneous,  852  (832-3) ;  Obturator,  849  (829) ;  these  should  be  exposed  in  place,  then  turn 
off  the  deep  fascia  (364)  and  expose  the  structures  underneath. 

The  hamstring  muscles,  384  ;  Fig.  291.     (382) 
Flexor  biceps  femoris,  384-5.     (382-3) 

Origin,  long  head,  short  head.     Insertion. 

Structure.     Nerve-supply.     Action.     Relations.     Variations. 
Semi-tendinosus,  385.     (383-4) 

Origin.     Insertion.     Structure.     Nerve-supply.     Action.     Relations. 
Semi-membranosus,  386-7.     (384-5) 

Origin.  Insertion.  Structure.   Nerve-supply.  Action.   Relations.   Variations. 

Note  the  bursx  found  in  connection  with  the  popliteal  tendons,  1226-7. 

Great  sciatic  nerve.     External  and  internal  popliteal  nerves,  858-9.     (838-9) 

Branches. 
Terminal  branches  of  the  perforating  arteries,  i-ii-iii-iv,  620.     (608-9) 

Divide  the  adductor  magnus  and  quadratus  femoris  at  their  origin  and  expose  the  obturator  externus. 
Carefully  raise  the  obturator  externus  and  trace  the  obturator  vessels  and  nerve.  Note  the  insertion  of 
the  psoas  and  iliacus. 

Obturator  externus,  383-4.     (382) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations. 
Obturator  artery,  606-7.     (595) 

External  branch.     Internal  branch. 
Obturator  nerve,  849.     (829—30) 

Twigs  from  anterior  and  posterior  branches  to  hip  joint,  and  to  muscles. 
Psoas  magnus,  366-7.     (365-6—7) 

Insertion.     Action.     Relations  in  the  thigh. 
Iliacus,  368.     (367) 

Insertion.     Action.     Relations. 
Note  : — Muscles  in  relation  with  the  hip  joint,  264.     (268) 

In  front.    Above.    Above  and  behind.    Below  and  behind.     Internally. 

LANDMARKS  OF  THE  LEG,  AXKLE,  AND  FOOT. 

The  Leg,  1228-1233.     (1204-1209) 
Bony  landmarks. 
Muscular  prominences. 
Vessels  :  — 

Saphena  veins ;  internal,  external. 

Popliteal  artery. 

Line  of  posterior  tibial  artery. 

Line  of  anterior  tibial  artery. 

The  Ankle,  1233.     (1209) 
Bony  landmarks  : — 

Malleoli ;  internal,  external. 

The  Foot,  1238.    (1214) 
Bony  landmarks:  — 

(A)  Along  the  inner  aspect  of  the  foot. 

(B)  Along  the  outer  aspect. 

Levels  of  the  joints  and  lines  of  operations,  1238-9-40.     (1214-15-16) 

Syme's  amputation. 

Pirogoff's  amputation. 

Chopart's  medio-tarsal  amputation. 

Lisfranc's  or  Key's  or  tarso-metatarsal  amputation. 

Amputation  of  the  great  toes. 
Line  of  dorsal  artery,  1242.     (1218) 
Line  of  plantar  arteries,  1242.     (1218) 


n6 


OUTLINES  OF  ANATOMY. 


Cutaneous  nerves,  1242.     (1218) 
Musculo-cutaneous  nerve. 
Anterior  tibial. 
External  saphenous  nerve. 
Internal  saphenous  nerve. 

Dissection  of  Front  of  Leg  and  Dorsal  Surface  of  Foot. 

Continue  the  median  incision  down  the  leg,  in  front  of  the  ankle  and  over  the  dorsum  of  the  foot  to  the 
second  toe.  Make  transverse  incisions  at  the  middle  of  the  leg,  at  the  ankle,  and  at  the  base  of  the  toes, 
also  a  median  incision  on  the  dorsum  of  each  toe,  to  the  end.  Reflect  the  skin  each  way  from  the 
median  incisions  and  expose  the  superficial  fascia,  veins,  and  cutaneous  nerves. 

Superficial  veins  of  the  lower  limb,  683-5  >  Fig.  397-     (669) 

Long  or  internal  saphenous  vein. 
Superficial  lymphatic  vessels,  705  ;  Fig.  400.     (689) 
Cutaneous  nerves,  Fig.  464;  P.  851.     (831) 

Long  or  internal  saphenous  nerve,  852-3.     (833) 

Cutaneous  branches  of  the  external  popliteal,  859.     (839) 

Branches  of  the  musculo-cutaneous,  859.     (839) 
Internal  branch.     External  branch. 

Internal  branch  of  the  anterior  tibial,  861.     (841) 

External  or  short  saphenous,  861.     (841) 
Turn  off  the  superficial  fascia  and  expose  the  deep  fascia  of  the  leg. 
Deep  fascia  of  the  leg,  390.     (388) 
Anterior  annular  ligament,  1237(1213);  also,  390-1.     (388) 

Upper,  above  the  level  of  the  ankle-joint. 

Lower,  over  the.  ankle-joint. 

Turn  off  the  deep  fascia,  leaving  the  annular  ligament  over  the  ankle-joint,  to  retain  the  tendons  in 
place.  As  each  muscle  is  exposed,  the  tendon  should  be  traced  to  its  terminal  insertion. 


(407) 


(409-10) 
Nerve-supply. 


Action.    Relations.    Variations. 


Relations.    Variations. 


Muscles  of  the  front  of  the  leg,  410;  Figs.  297-8. 
Tibialis  anticus,  410.     (407) 

Origin.     Insertion.     Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Extensor  longus  digitorum,  412-13. 
Origin.    Insertion.     Structure. 
Peroneus  tertius,  413-14.     (410) 

Origin.    Insertion.     Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Extensor  proprius  hallucis,  410-11-12.     (407-8-9) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action. 
Tendons  in  front  of  ankle,  1233-4.     (1209-10) 
Bursae  and  synovial  membranes,  1241.     (1217) 
Extensor  brevis  digitorum,  415.     (411-12) 

Origin.    Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Anterior  tibial  nerve,  859-60-1  ;  Fig.  468.     (839-40-1) 
Branches: — Internal  branch. 
External  branch. 

Musculo-cutaneous  nerve,  859;  Fig.  468. 
External  branch. 
Internal  branch. 

Anterior  tibial  artery,  course  of  the  vessel,  632-3-4;  Fig.  380.     (620-1-2) 
Relations: — Posteriorly.     Inner  side.      Outer  side.     In  front. 
Branches  of  the  anterior  tibial  artery  : — 
Anterior  tibial  recurrent. 
Muscular  branches. 
Internal  malleolar. 
External  malleolar. 

Dorsalis  pedis  artery,  634-6-7  ;  Fig.  380. 
Relations: — Behind.     In  front. 


(839) 


(622-4-5) 
Outer  side. 


Inner  side. 


Branches  of  the  dorsalis  pedis  artery,  636. 
Tarsal  branches : — 

Internal  tarsal. 
External  tarsal. 


(624) 


THE  ABDOMINAL    WALLS.  117 

Metatarsal  artery  :  — 

Dorsal  interosseous  arteries. 
Dorsal  digital  vessels. 
Dorsalis  hallucis: — 

Dorsal  digital  branches. 
Communicating. 

Anterior  peroneal  artery,  627;  Fig.  380.     (615) 
Deep  veins — of  the  lower  extremity,  683  and  685.     (669  and  671) 
Deep  lymphatic  vessels  of  the  lower  limb,  707.     (691) 
Peroneal  Region. 

Turn  off  the  deep  fascia  covering  the  peronei  muscles,  leave  enough  of  the  external  annular  ligament 
to  retain  the  tendons  in  place  as  they  pass  under  it. 

External  annular  ligament,  391  and  1237.     (388  and  1213) 

Muscles  on  the  outer  side  of  the  leg,  415  ;  Figs.  292,  297.     (412) 

Peroneus  longus,  415-16.     (412-13) 

Origin.     (Insertion.)     Structure.      Nerve-supply.     Action.      Relations.     Vari- 
ations. 

Peroneus  brevis,  417.     (413-14) 

Origin.     (Insertion.)     Structure.      Nerve-supply.     Action.      Relations.     Vari- 
ations. 

External  popliteal  nerve,  859.     (839) 
Recurrent  articular  nerve. 
Musculo-cutaneous  nerve. 
Anterior  tibial  nerve. 

Posterior  Tibio-Fibular  Region. 

Note  the  cutaneous  nerve-supply,  Fig.  464;  P.  851.     (831) 

Continue  the  median  incision  to  the  middle  of  the  heel.  Make  a  transverse  incision  from  the  internal 
to  the  external  malleolus,  passing  under  the  middle  of  the  heel.  Reflect  the  skin  from  the  posterior 
surface  of  the  leg  and  from  the  posterior  portion  of  the  heel,  exposing  the  superficial  fascia,  veins,  and 
nerves. 

Superficial  veins  of  the  lower  limb,  683-5.     (669-71) 

Branches  of  internal  saphenous  vein. 

The  short  or  external  saphenous  vein. 
Cutaneous  nerves,  Fig.  464;  P.  851.     (831) 

Posterior  branch  of  the  internal  cutaneous  nerve,  852.     (832-3) 

Internal  saphenous  nerve,  852-3.     (833) 

Internal  calcanean  or  calcaneo-plantar  cutaneous  branch,  863.     (843) 

Terminal  branches — of  the  small  sciatic  nerve,  856-7.     (837-8) 

External  or  short  saphenous  nerve,  varieties,  86 1.     (841) 
Deep  fascia  of  the  leg,  390.     (388) 

Internal  annular  ligament,  391  and  1237.     (388  and  1213) 

Divide  the  deep  fascia  in  the  median  line  and  turn  out  and  in  from  this  incision ;  preserve  a  portion  of 
the  internal  annular  ligament. 

Gastrocnemius,  391-3;  Fig.  291.     (389) 

Origin: — Outer  head;  inner  head.     Insertion. 
Structure.     Nerve-supply.     Relations.     Variations. 

Divide  the  gastrocnemius  transversely  about  three  inches  above  the  tendo-Achillis  and  raise  the  upper 
portion  to  expose  the  structures  underneath. 

Plantaris,  393.     (391) 

Origin.     Insertion.    Structure.    Nerve-supply.    Action.    Relations.    Variations. 
Soleus,  394-5-6.     (392-3) 

Origin.     Insertion.     Structure,  tendo-Achillis  (behind  the  ankle,  1235).    (1210) 

Nerve-supply.     Action.     Variations. 

Divide  the  soleus  transversely  in  the  same  manner  as  the  gastrocnemius  and  raise  to  expose  the  struc- 
tures underneath,  then  divide  the  upper  portion  of  the  muscle  vertically  in  the  median  line,  note  the 
tendinous  arch  of  origin  (3)  between  the  tibia  and  fibula. 


n8  OUTLINES  OF  ANATOMY, 

Deep  tibial  fascia,  396.     (393) 

Popliteal  artery ;  terminal  branches,  625;  Fig.  374.     (613) 
Anterior  tibial  artery,  632.     (620) 

Posterior  tibial  recurrent,  634.     (620) 
Posterior  tibial  artery,  626-7;  Fig.  377.     (614-15) 

Relations  : — Anteriorly.     Posteriorly.     At  the  inner  ankle. 
Branches,  628.     (615-16) 

Muscular  branches.     Medullary  artery.     Cutaneous  branches. 
Communicating  branch. 
Malleolar  or  internal  malleolar  branches. 
Calcanean  or  internal  calcanean  branch. 
Vessels  divided  in  amputation,  1233.     (1209) 
Posterior  tibial  nerve,  862-3.     (842-3) 
Branches : — 

Internal  calcanean  or  calcaneo-plantar  branch. 
Deep  lymphatic  vessels  of  the  lower  limb,  707.     (691) 
Deep  lymphatic  glands  of  the  lower  extremity,  707.     (691) 
Popliteus,  394;  Fig.  292.     (391-2) 

Origin.    Insertion.    Structure.     Nerve-supply.    Action.    Relations.    Variations. 

Expose  and  separate  the  deep  muscles,  follow  the  tendons  to  the  annular  ligament ;  the  insertion  will 
be  shown  later  in  the  dissection  of  the  foot. 

Flexor  longus  hallucis,  398;  Fig.  292.     (395-6) 

Origin.     (Insertion.)     Structure.      Nerve-supply.     Action.      Relations.     Vari- 
ations. 
Flexor  longus  digitorum,  396-7  ;  Fig.  292.     (393-4-5) 

Origin.     (Insertion.)     Structure.      Nerve-supply.     Action.      Relations.     Vari- 
ations. 
Tibialis  posticus,  398-9  ;  Fig.  292.     (396) 

Origin.     (Insertion.)     Structure.     Nerve-supply.     Action.     Relations. 
Peroneal  artery,  627-8;  Fig.  377.     (615-16) 
Branches  of  the  peroneal  artery  : — 

Muscular  branches.     Medullary.     Communicating  branches. 
Cutaneous  branches.     External  calcanean.     Terminal  branch. 
Anterior  peroneal  artery,  Fig.  380. 
Points  in  tenotomy  and  guides  to  the  tendons,  1237-8.     (1213-14) 

Tendo-Achillis.     Tibialis  anticus.     Tibialis  posticus.     Peronei. 

Sole  of  the  Foot. 

Continue  the  median  incision  to  the  end  of  the  middle  toe.  Make  a  transverse  incision  at  the  base  of  the 
toes,  and  from  this  a  median  incision  to  the  end  of  each  toe,  remove  the  skin,  exposing  the  superficial 
fascia  and  cutaneous  nerves. 

The  sole  of  the  foot  is  supplied  by  the  internal  calcanean  or  calcaneo-plantar  cutane- 
ous branch  of  the  posterior  tibial,  and  cutaneous  branches  from  the  internal  plantai 
and  external  plantar  nerves,  863  ;  Fig.  469.  (843) 

Dissect  off  the  superficial  fascia  and  expose  the  plantar  fascia.  Carefully  preserve  the  superficial  nerves 
and  vessels. 

Plantar  fascia,  399-400-1.     (397—8) 

Central  part.     Inner  portion.     External  portion. 
Superficial  transverse  ligament. 

"  The  lateral  portions  of  the  plantar  fascia  should  be  raised  from  the  subjacent  muscles.  The  three 
superficial  muscles  of  the  sole  are  then  exposed  to  view  and  their  connections  can  be  studied.  The 
flexor  brevis  digitorum  is  placed  in  the  middle,  the  abductor  minimi  digiti  extends  along  the  outer  mar- 
gin of  the  sole,  and  the  abductor  hallucis  along  the  inner  margin  of  the  sole.  In  the  interval  between 
the  abductor  hallucis  and  flexor  brevis  digitorum  the  internal  plantar  nerve  and  artery  will  be  found. 
Follow  the  nerve  toward  the  toes  and  dissect  out  its  four  digital  branches.  In  doing  so,  care  must  be 
taken  of  the  muscular  twigs  which  are  given  to  the  flexor  brevis  hallucis  and  the  innermost  lumbrical 
muscle.  Slender  branches  of  the  internal  plantar  artery  accompany  the  digital  nerves.  Now  trace  the 
trunk  of  the  internal  plantar  nerve  backward  by  carefully  separating  the  flexor  brevis  digitorum  and 
the  adductor  hallucis  along  the  line  of  the  intermuscular  septum.  It  will  be  found  to  give  a  branch  of 
supply  to  each  of  these  muscles.  In  the  next  place,  separate  the  contiguous  borders  of  the  flexor  brevis 


THE  ABDOMINAL    WALLS.  119 

digitorum  and  abductor  minimi  digiti.  The  external  plantar  artery  and  nerve  lie  for  a  short  portion  of 
their  course  in  the  interval  between  these  muscles.  Approaching  the  prominent  base  of  the  fifth  meta- 
tarsal  bone,  the  artery  disappears  from  view  by  turning  inward  under  cover  of  the  flexor  tendon.  At 
the  same  point  the  external  plantar  nerve  divides  into  its  superficial  and  deep  divisions.  The  deep 
division  of  the  external  plantar  nerve  cannot  be  dissected  at  present,  as  it  accompanies  the  external 
plantar  artery.  The  superficial  division,  however,  should  be  traced  to  its  distribution."  (Cunningham.) 

Flexor  brevis  digitorum  or  flexor  perforatus,  401-2  ;  Fig.  293.     (399) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations.  Variations. 
Abductor  hallucis,  401  ;  Fig.  293.  (398-9) 

Origin: — Outer  head  ;  Inner  head.     Insertion.     Structure. 

Nerve-supply.     Action.     Relations.     Variations. 
Abductor  minimi  digiti,  402-3  ;  Fig.  293.     (399-400) 

Origin.     Insertion.     Structure.     Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  muscles  of  the  superficial  group  near  their  origin  from  the  os  calcis  and  turn  them  forward ; 
note  the  arterial  and  nerve  branches  to  each,  expose  the  superficial  portion  of  the  plantar  arteries  and  the 
plantar  nerves. 

Internal  plantar  artery,  631-2  ;  Fig.  378.     (619-20) 

Relations.     Branches  : — Muscular  branches.     Cutaneous  branches. 

Articular.     Anastomotic.     Superficial  digital. 

External  plantar  artery  (superficial  portion),  628-9  ;  Fig.  378.     (616-17) 
Relations  in  the  first  part  of  its  course,  629-30.     (617) 
Branches  of  the  external  plantar  artery  :  — 

Muscular  branches.     Calcanean.     Cutaneous.     Anastomotic. 
The  veins  of  the  foot  and  leg,  685.     (671) 
Internal  plantar  nerve;  cutaneous  branches,  863  ;  Fig.  469.     (843) 

First  digital  branch.     Second  branch.     Third  branch.     Fourth  branch. 
External  plantar  nerve,  863  ;  Fig.  469.     (843) 
Superficial  division  : — 
Internal  branch. 
External  branch. 

Expose  the  tendon  of  the  flexor  longus  digitorum,  and  trace  forward  each  division  to  its  terminal  inser- 
tion. 

Flexor  longus  digitorum,  396 ;  Fig.  294.     (393-4-5) 

Insertion.     Structure.     Action. 
Flexor  accessorius  digitorum  pedis,  404 ;  Fig.  294.     (400-1) 

Origin  : — Inner  head  ;  Outer  head.     Insertion.     Structure. 
Xerve-supply.     Action.     Relations.     Variations. 
The  four  lumbricales,  404-5  ;  Fig.  294.     (401-2) 

Origin.     Insertion.     Structure.     Xerve-supply.     Action.     Relations. 
Flexor  longus  hallucis,  398 ;  Fig.  294.     (395) 
Insertion.     Structure.     Action. 

To  expose  the  next  layer  of  muscles,  divide  the  flexor  accessorius  at  its  origin,  cut  the  tendons  of  the 
flexor  longus  digitorum  and  the  flexor  longus  hallucis  in  front  of  the  annular  ligament  and  turn  forward 
to  the  toes.  Leave  the  plantar  vessels  and  nerves  in  place. 

Flexor  brevis  hallucis,  405-6  ;  Figs.  294-5.     (402-3) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations.  Variations. 
Adductor  hallucis,  406-7  ;  Fig.  295.  (403-4) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations.  Variations. 
Transversus  pedis,  407  ;  Fig.  295.  (404) 

Origin.  Insertion.  Structure.  Nerve-supply.  Action.  Relations.  Variations. 
Flexor  brevis  minimi  digiti,  407—8;  Fig.  295.  (404—5) 

Origin.     Insertion.     Structure.     Nerve-supply.    Action.    Relations.    Variations. 

Divide  the  flexor  brevis  and  the  adductor  hallucis  at  their  origin,  and  throw  them  forward  to  expose  the 
plantar  arch  and  the  deep  branch  of  the  external  plantar  nerve. 

Plantar  artery  ;  second  part  of  its  course,  630-1 ;  Fig.  379.     (618-19) 
Branches  : — Articular. 

Digital  or  plantar  digital  : — 
Collateral  digital  arteries. 


120  OUTLINES  OF  ANATOMY. 

Fifth  plantar  digital  or  princeps  hallucis,  637.     (625) 

Posterior  perforating,  630.     (618) 

Deep  division  of  the  external  plantar  nerve,  863.     (843) 

The  heads  of  the  metatarsal  bones  are  connected  on  their  plantar  aspect  by   the 
transverse  ligament,  293.     (296) 

Divide  the  transverse  ligament,  separate  the  toes  and  expose  the  interosseous  muscles.     Note  the  com- 
munication between  the  dorsal  and  plantar  arteries. 

The  interossei : — Plantar;  Dorsal,  408-9;  Fig.  296.     (405-6) 
Plantar  interossei : — 

Origin.     Insertion. 
Dorsal  interossei: — Insertion. 
Structure.     Nerve-supply. 
Action  of: — Plantar  interossei. 
Dorsal  interossei. 
Relations. 

Trace  the  tendons  and  demonstrate  the  insertion  of  the  tibialis  posticus ;  peroneus  brevis  ;  and  peroneus 
longus. 

Tendons  on  inner  side  of  ankle,  1235-6-7.     (1211-12-13) 
Tibialis  posticus,  399.     (396) 

Insertion.     Action. 

Tendons  at  outer  ankle,  1237.     (1213) 
Peroneus  brevis,  417.     (413) 
Insertion.     Action. 
Peroneus  longus,  415-16.     (412-13) 

Insertion.     Structure.     Action. 

Demonstrate  the  anastomosis  about  the  knee-joint,  Fig.  376,  P.  625  (613),  also  about  the  ankle-joint, 
and  foot,  Fig.  381,  P.  635.     (623) 

Remove  the  muscles  from  the  pelvis  and  lower  extremity,  leaving  about  four  inches  of  each  flexor  ten- 
don at  the  knee-joint ;  demonstrate  the  ligaments  of  each  joint  as  indicated. 

The  Articulations,  186-7.     (195-6) 

Bones. 
Cartilage: — 

Articular;  hyaline  variety. 
White  fibrous: — 

As  interarticular  cartilage. 
As  circumferential. 
As  connecting  fibro-cartilage. 
The  ligaments. 
Synovial  membrane. 

THE  VARIOUS  KINDS  OF  ARTICULATIONS,  187-8.     (196-7) 

Synarthrosis : — 

True  sutures. 

False  sutures. 

Grooved  sutures. 
Amphiarthrosis. 
Diarthrosis:  — 

Arthrodia. 

Ginglymus,  ginglymo-arthrodial. 
Enarthrodia.     Trochoides. 
Table  of  the  various  classes  of  joints. 

THE  VARIOUS  MOVEMENTS  OF  JOINTS,  188-9.     (:97-8) 
Gliding.     Angular.     Rotation.     Circumduction. 


THE  ABDOMINAL    WALLS.  121 

THE  ARTICULATION"  OF  THE  PELVIS  WITH  THE  SPINE,  209-10-11.     (216-17-18) 

Sacro-lumbar  ligament. 
Ilio-lumbar  ligament. 
Arterial  supply.     Nerve-supply. 
Movements. 

ARTICULATIONS  OF  THE  PELVIS,  211 ;  Figs.  206  to  213.     (218) 

(a)  Sacro-iliac. 

(b)  Sacro-coccygeal. 

(c)  Intercoccygeal. 

(d)  Symphysis  pubis. 

(a)  Sacro-iliac  synchondrosis  and  sacro-sciatic  ligaments,  211-12-13-14.     (218-19-20-21) 

Class — Amphiarthrosis. 
Anterior  sacro-iliac  ligament. 
Superior  sacro-iliac  ligament. 
Posterior  sacro-iliac  ligament. 
Inferior  sacro  iliac  ligament. 
Interosseous  ligament. 

Ear- shaped  cartilaginous  plate. 

Great  or  posterior  sacro-sciatic  ligament.     Falciform  process. 
Small  sacro-sciatic  ligament. 

Arterial  supply.     Nerve  supply.     Movements. 

(b)  Sacro-coccygeal  articulation,  214-15-16.     (221-2-3) 

Cl  ass — A  mph  ia  rth  rosis. 
Anterior  sacro- coccygeal  ligament. 
Posterior  sacro- coccygeal  ligament.. 
Supracornual  ligament. 
Intertransverse  ligament. 
Intervertebral  substance. 

Arterial  supply.     Nerves.     Movements. 

(c)  Intercoccygeal  Joints,  216.     (223) 

(d)  The  Symphysis' Pubis,  216-17-18.     (223-4-5) 

C 1  ass — A  mph  ia  rth  rosis. 
Superior  ligament. 
Posterior  ligament. 
Anterior  ligament. 
Inferior  or  infrapubic  ligament. 
Interosseous  cartilage. 

Arterial  supply.     Nerve- supply.     Movements. 

THE  ARTICULATIONS  OF  THE  LOWER  LIMB,  258.     (263) 
i,  2,  3,  4,  5,  6,  7,  8,  9. 

1.  THE  HIP  JOINT,  259  to  266 ;  Figs.  237  to  244.     (263  to  270) 

Class — Diarthrosis.     Subdivision — Enarthrodia. 
Capsular  ligament,  at  pelvis,  at  femur.     Retinacula. 
Ilio-femoral. 
Ischio-femoral  band. 
Pectineo-femoral  band. 
Tendino-trochanteric  band. 

Open  the  capsular  ligament,  demonstrate  the  ilio-femoral  band,  then  divide  it. 

Ligamentum  teres. 
Transverse  ligament. 
Cotyloid  fibro-cartilage. 
Synovial  membrane. 

Arterial  supply.     Nerve-supply. 

Movements. 

2.  THE  KNEE-JOINT,  266  to  277  ;  Figs.  245  to  252.     (271  to  280) 

Class — Diarthrosis.     Subdivision —  Ginglymus. 
External  ligaments : — 

The  fibrous  expansion  of  the  extensor  tendons. 

Ligamenium  patellae. 

Internal  lateral  ligament. 

External  lateral  ligament. 

Posterior  lateral  ligament,  or  ligamentum  Winslowii. 

Capsular  or  anterior  ligament. 

Open  the  joint  in  front,  cutting  the  ligaments  transversely  above  the  patella.     Demonstrate  the  internal 
ligaments  and  the  cartilages. 
9 


122  OUTLINES   OF  ANATOMY. 

Internal  ligaments : — 

Anterior  crucial  ligament. 
Posterior  crucial  ligament. 
Interarticular  or  semilunar  fibro-cartilages. 
External  semilunar  cartilage. 
Internal  semilunar  cartilage. 
Transverse  ligament. 
Coronary  ligaments. 
Synovial  membrane:  (also,  1223-4).     (1199—1200) 

Ligamentum  mucosum.     Alar  ligaments. 
Arterial  supply. 
Nerve-supply : — 

Great  sciatic.     Anterior  crural.     Obturator. 
Movements : — 

Antero  posterior  spiral  curve. 

Extension.     Flexion.     Pronation. 

Supination.     Sliding  movements. 

3.  THE  TiBio-FiBULAR  UNION,  277-8-9.     (281-2-3) 

(a)  Superior  tibio-fibular  joint. 

(b)  Middle  tibio-fibular  union. 

(c)  Inferior  tibio-fibular  joint. 

(a)  Superior  tibio-fibular  joint. 

Class — Diarthrosis.     Subdivision — Arthrodia. 
Capsular  ligament. 
Anterior  tibio-fibular  ligament. 
Posterior  tibio-fibular  ligament. 
Superior  interosseous  ligament. 
Biceps  tendon. 
Synovial  membrane. 
Arterial  supply.     Nerve-supply.     Movements. 

(b)  Middle  tibio  fibular  union. 
The  interosseous  membrane. 

(c)  Inferior  tibio-fibular  articulation. 

Class — Diarthrosis.     Subdivision — Arthrodia. 
Anterior  inferior  tibio-fibular  ligament. 
Posterior  inferior  tibio-fibular  ligament. 
Inferior  interosseous  ligament. 
Transverse  ligament. 
Synovial  membrane. 
Nerve-supply.     Movements. 

4.  THE  ANKLE-JOINT,  279-80-1-2  ;  Figs.  253-4-5.     (283-4-5) 

Class — Diarthrosis.     Subdivision —  Ginglymus. 
Anterior  ligament. 
Posterior  ligament. 
Internal  lateral  or  deltoid  ligament. 
External  lateral  ligament : — 

Anterior  fasciculus.     Middle  fasciculus.     Posterior  fasciculus. 
Synovial  membrane. 
Nerve-supply.     Arterial  supply. 
Movements. 

5.  THE  TARSAL  JOINTS,  282  to  290  ;  Figs.  253  to  258.     (286  to  293) 

(a)  Calcaneo-astragaloid  union. 

(b)  Articulations  of  the  anterior  portion  of  the  tarsus. 

(c)  Medio-tarsal  joint. 

Synovial  membranes  in  tarsus,  1241-2.     (1217-18) 
(a)  Calcaneo-astragaloid  union. 

Class — Diarthrosis.     Subdivision — Arthrodia. 
(i)  Posterior  calcaneo-astragaloid  joint. 

Interosseous  ligament,  anterior  interosseous  ligament. 

External  calcaneo-astragaloid  ligament. 

Posterior  calcaneo-astragaloid  ligament. 

Internal  calcaneo-astragaloid  ligament. 

Synovial  sac. 

Nerve-supply.     Arteries. 


THE  ABDOMINAL    WALLS.  123 


(ii)  Anterior  calcaneo-astragaloid  joint. 
Interosseous  ligament. 
Antero-internal-calcaneo-astragaloid. 
External  calcaneo-scaphoid. 
Movements. 
Synovial  membrane. 
Arteries.     Nerves. 

(b)  The  articulations  of  the  anterior  part  of  the  tarsus. 

Class — Diarthrosis.     Subdivision — Arthrodia. 
(i)  Cubo-scaphoid  union. 

Dorsal  cubo-scaphoid  ligament. 

Plantar  cubo-scaphoid  ligament. 

Interosseous  cubo-scaphoid  ligament, 
(ii)  Scapho-cuneiform  articulation. 

Dorsal  scapho- cuneiform  ligament. 

Internal  scapho- cuneiform  ligament. 

Plantar  scapho-cuneiform  ligament, 
(iii)  Intercuneiform  and  (iv)  cubo-cuneiform  articulations. 

Dorsal  ligaments. 

Plantar  ligaments. 

Interosseous  ligaments. 

Arterial  supply.     Nerves.     Movement. 

(c)  The  medio-tarsal  or  transverse  tarsal  joints. 

(i)  Astragalo-scaphoid  articulation. 

External  calcaneo-scaphoid  ligament. 

Inferior  calcaneo-scaphoid  ligament. 

Astragalo-scaphoid  ligament. 

Synovia!  membrane, 
(ii)  Calcaneo-cuboid  articulation. 
Class — Diarthrosis.     Subdivision — Arthrodia. 

Internal  or  interosseous  calcaneo-cuboid  ligament. 

Dorsal  calcaneo-cuboid  ligament. 

Long  inferior  calcaneo-cuboid. 

Short  inferior  calcaneo-cuboid. 

Synovial  membrane. 

Arterial  supply.     Nerve-supply. 

Movements,  lateral  motion. 

6.  TARSO-METATARSAL  ARTICULATIONS,  290-1-2.     (293-4-5) 

Class — Diarthrosis.     Subdivision — Arth  rodia . 
Three  articulations — (a),  (b),  (c). 

Arteries  for  tarso  metatarsal  joints. 
Nerve-supply.     Movements. 

(a)  Internal  tarso-metatarsal  joint. 

(b)  Middle  tarso-metatarsal  joint. 

The  dorsal  ligaments. 

The  plantar  ligaments.  . 

The  interosseous  ligaments. 

Synovial  membrane. 

(c)  Cubo-metatarsal  joint. 

Plantar  cubo-metatarsal  ligament. 

External  cubo-metatarsal  ligament. 
Dorsal  cubo-metatarsal  ligament. 
Interosseous  ligament. 
Synovial  membrane. 

7.  INTERMETATARSAL  ARTICULATIONS. 

Dorsal  ligaments. 
Plantar  ligaments. 
Interosseous  ligaments. 
Synovial  membrane. 
Arterial  and  nerve-supply. 
Movements. 

The  union  of  the  heads  of  the  metatarsal  bones. 
Transverse  ligament. 


i24  OUTLINES  OF  ANATOMY. 

ARCHES  OF  THE  FOOT,  1242-3-4-5-6-7. 

Longitudinal  and  transverse. 

A.  Longitudinal  arch  : — 

Extent. 
Two  pillars. 

Posterior  pillar. 
Anterior  pillar. 
Inner  pillar. 
Outer. 
Keystone. 

B.  Transverse  arch. 
Uses  of  the  arches. 
Maintenance  of  the  arch  : — 

Plantar  fascia. 

Calcaneo-scaphoid  ligament. 
Calcaneo-cuboid  ligaments: — 

Long.     Short. 
Tibialis  posticus. 
Peroneus  longus. 
Tibialis  anticus. 

8.  THE  METATARSO-PHALANGEAL  ARTICULATIONS,   293-4.     (296-7) 

(a)  Metatarso-phalangeal  joints  of  the  four  outer  toes. 

Class — Diarthrosis .     Subdivision —  Ginglymus. 
Two  lateral  ligaments. 
Dorsal  ligament. 
Plantar  sesamoid  plate. 

(b)  Metatarso-phalangeal  joints  of  the  great  toe. 
Arteries.     Movements. 

9.  INTERPHALANGEAL  JOINTS,  294.     (297) 

Class — Diarthrosis.     Subdivision —  Ginglymus. 
Two  lateral. 
Dorsal  ligaments. 
Glenoid  ligament. 
Arteries.     Nerves.     Movements. 
Morphology  of  ligaments,  294-5.     (297-8) 


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